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A  TEXT-BOOK 


OF 


DISEASES  OF  WOMEN 


BY 


CHARLES  B.  PENROSE,  M.D*,  Ph.D, 

Formerly  Professor  of  Gynecology  in  the  University  of  Pennsylvania ; 
Surgeon  to  the  Gyneccan  Hospital,  Philadelphia 


Mitb  221   iruustrations 


FOURTH  EDITION,  REVISED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  &  COMPANY 
J902 


Copyright,  1901, 
By  W.  B.  SAUNDERS   &  COMPANY. 


Registered  at  Stationers'  Hall,  London,  England. 


ELECTROTYPED  BY  PRESS  OF 

WESTCOTT  &.  THOMSON,   PHILAOA.  '  W.   B.   SAUNDERS  &  COMPANY. 


PREFACE  TO  THE  FOURTH  EDITION. 


I  HAVE  carefully  revised  this  book  for  the  fourth 
edition,  and  have  made  numerous  additions  which  have 
been  rendered  necessary  by  the  increase  of  our  knowl- 
edge of  gynecology. 

I  am  indebted  to  Dr.  H.  D.  Beyea  for  valuable  assist- 
ance in  the  preparation  of  this  edition. 

CHARLES  B.  PENROSE. 

1720  Spruce  Street,  Philadelphia. 


347524 


PREFACE. 


I  HAVE  written  this  book  for  the  medical  student.  I 
have  attempted  to  present  the  best  teaching  of  modern 
gynecology,  untrammelled  by  antiquated  theories  or 
methods  of  treatment.  I  have,  in  most  instances,  recom- 
mended but  one  plan  of  treatment  for  each  disease,  hop- 
ing in  this  way  to  avoid  confusing  the  student  or  the 
physician  who  consults  the  book  for  practical  guidance. 
I  have,  as  a  rule,  omitted  all  facts  of  anatomy,  phys- 
iology, and  pathology  which  may  be  found  in  the  gen- 
eral text-books  upon  these  subjects.  Such  facts  have 
been  mentioned  in  detail  only  when  it  seemed  important 
for  the  elucidation  of  the  subject,  or  when  there  were 
certain  points  in  the  pathology  that  were  peculiar  to  the 
diseases  under  consideration.  I  am  indebted  to  Dr.  H. 
D.  Beyea  for  several  pathological  drawings,  and  to  Dr. 
Wm.  R.  Nicholson  for  the  preparation  of  the  Index. 

CHAS.   B.  PENROSE. 
1 33 1  Spruce  Street,  Philadelphia. 


CONTENTS. 


CHAPTER  I. 

PAGE 

The  Generai.  Causes  of  Diseases  op  Women 17 


CHAPTER  II. 

Methods  of  Examination -   .    21 

Examination  of  the  Abdomen,  21. — Examination  of  the  External 
Genitals  and  Pelvic  Structures,  24. — Vaginal  and  Bimanual  Examina- 
tion, 25. — Examination  of  the  Rectum,  35. — Examination  of  the  Blad- 
der, 36. 

CHAPTER  III. 

Diseases  of  the  Externai.  Genitals 38 

Vulvitis,  38. — Inflammation  of  the  Vulvo-vaginal  Glands,  40. — Sup- 
puration of  the  Vulvo-vaginal  Gland,  41. — Cysts  of  the  Vulvo-vaginal 
Glands,  42. — Pruritus  Vulvse,  44. — Kraurosis  Vulvae,  46. — Varicose 
Tumors  of  the  Vulva,  48.— Hematoma  of  the  Vulva,  48. — Papilloma, 
48. — Elephantiasis,  49. — Adhesions  of  the  Clitoris,  49. 

CHAPTER  IV. 
Diseases  of  the  Vagina 51 

Inflammation  of  the  Vagina,  51. — Tumors  of  the  Vagina,  53. 

CHAPTER  V. 
Anatomy  and  Mechanism  of  the  Perineum 55 

CHAPTER  VI. 

Injuries  to  the  Perineum 60 

Slight  Median  Laceration  of  the  Perineum,  65.— Median  Tear  in- 
volving the  Sphincter  Ani,  66. — Laceration  through  the  Sphincter  Ani, 
involving  the  Recto- vaginal  Septum,  71. — Laceration  in  One  or  Both 
Vaginal  Sulci,  73. — Subcutaneous  Laceration  of  the  Muscles  and  Fas- 
cia, 83. 

11 


12  CONTENTS. 

CHAPTER  VII. 

PAGE 

Results  of  lyAcERATioN  of  the  Pfrineum 85 

Rectocele,  85. — Cystocele,  86. — Enterocele,  90. — Subinvolution  of 
the  Vagina,  90. 

CHAPTER  VIII. 
The  Position  op  the  Uterus  and  the  Mechanism  of  its 
Support = 92 

CHAPTER  IX. 
Prolapse  of  the  Uterus ,  .  .   99 

CHAPTER  X. 
Anteflexion  of  the  Uterus 107 

CHAPTER  XL 
Retroflexion  and  Retroversion  of  the  Uterus  .   .  .  .125 

CHAPTER  XII. 
Laceration  of  the  Cervix  Uteri "  146 

CHAPTER  XIII. 
Inflammation  of  the  Cervical  Mucous  Membrane  (Cer- 
vical Catarrh) 164 

CHAPTER  XIV. 
Congenital  Erosion  and  Split  of  the  Cervix ^ijz 

CHAPTER  XV. 
Cervical   Polypi  ;    Hypertrophic    Elongation    of   the 
Cervix  ;  Chancre  of  the  Cervix  ;  Tuberculosis  of 
THE  Cervix 176 

Cervical  Polypi,  176. — Hypertrophic  Elongation  of  the  Vaginal  Cer- 
vix, 177. — Chancre  of  the  Cervix,  178. — Tuberculosis  of  the  Cervix, 
178. 

CHAPTER   XVI. 
Cancer  of  the  Cervix  Uteri ,  ...  179 

CHAPTER   XVH. 
Diseases  of  the  Body  of  the  Uterus 197 

Acute  Corporeal  Endometritis,  197. — Chronic  Corporeal  Endome- 
tritis, 199. — Exfoliative  Endometritis,  or  Membranous  Dysmenorrhea, 
210. — Senile  Endometritis,  211. 


CONTENTS.  13 

CHAPTER   XVIII. 

PAGE 

Subinvolution  of  the  Uterus;  Superinvolution  of  the 
Uterus 213 

'  CHAPTER  XIX. 
Cancer  and  Sarcoma  of  the  Uterus .  216 

Cancer  of  the  Body  of  the  Uterus,  216. — Malignant  Adenoma,  219. 
— Sarcoma  of  the  Uterus,  223. — Diffuse  Sarcoma  of  the  Mucous  Mem- 
brane, 223. — Sarcoma  of  the  Uterine  Parenchyma,  225. 

CHAPTER  XX. 
Fibroid  Tumors  of  the  Uterus 227 

CHAPTER  XXI. 
Hematometra;  Hydrometra;  Pyometra  .   .......   .255 

CHAPTER  XXII. 
Tuberculosis  of  the  Uterus ,<,,.,..  257 

CHAPTER  XXIII. 
Inversion  of  the  Uterus 260 

CHAPTER    XXIV. 
Diseases  of  the  Fallopian  Tubes 268 

Inflammation  of  the  Fallopian  Tubes,  or  Salpingitis,  272. — Acute 
Salpingitis,  273. — Chronic  Salpingitis,  275. — Suppuration  of  the  Pelvic 
Cellular  Tissue,  299. 

CHAPTER   XXV. 

Diseases  of  the  Fallopian  Tubes  [Contimied) 302 

Tuberculosis,  302. — Adenoma,  Myoma,  Cancer,  Actinomycosis,  and 
Syphilitic  Gummata  of  the  Fallopian  Tubes,  309. 

CHAPTER  XXVI. 
Tubal  Pregnancy 310 

CHAPTER  XXVII. 
Diseases  of  the  Ovaries 326 


14  CONTENTS. 

CHAPTER  XXVIII. 


PAGB 


Diseases  of  the  Ovaries  {Continued)     330 

Hernia  of  the  Ovary,  330. — Prolapse  of  the  Ovary,  331. — Inflam- 
mation of  the  Ovary;  Oophoritis,  or  Ovaritis,  335. — Acute  Oophoritis, 
335. — Chronic  Oophoritis,  337. — Apoplexy  of  the  Ovary,  342. — Ova- 
rian Hydrocele,  342. 

CHAPTER   XXIX. 

Cystic  Tumors  of  the  Ovary 345 

Oophoritic  Cysts,  346. — Follicular  Cysts,  346. — Glandular  Cysts, 
250. — Dermoid  Cysts,  355. — Teratoma,  357. — Paroophoritic  Cysts,  or 
Papillomatous  Ovarian  Cysts,  358. 

CHAPTER  XXX. 
Cysts  of  the  Parovarium 363 

Comparison  of  Oophoritic,  Paroophoritic,  and  Parovarian  Cysts,  368. 
— Glandular  Oophoritic  Cyst,  368. — Paroophoritic  Cyst,  369. — Cysts 
of  the  Parovarium,  369. 

CHAPTER   XXXI. 

Natural  History  and  Treatment  of  Ovarian  Cysts  .  .  370 
Secondary  Changes  or  Accidents  of  Ovarian  Cysts,  370. — Inflam- 
mation and  Suppuration,  370. — Torsion  of  the  Pedicle,  or  Axial  Ro- 
tation, 371. — Rupture  of  Ovarian  Cysts,  373. — The  Clinical  History 
of  Ovarian  Cysts,  374. — Examination,  379. — Treatment  of  Ovarian 
Cysts,  383. 

CHAPTER   XXXII. 

Solid  Tumors  op  the  Ovary     386 

Fibromata,  386. — Myomata,  386. — Sarcomata,  387. — Carcinomata, 
388. — Ovarian  Papillomata,  389. — Tuberculosis  of  the  Ovary,  389. — 
Tumors  of  the  Ovarian  Ligament,  390. 

CHAPTER  XXXIII. 
Malformations  of  the  Genital  Organs 391 

Uterus  Unicornis,  392. — Uterus  Didelphys,  392. — Uterus  Bicornis 
Duplex,  392. — Uterus  Bicornis  UnicoUis,  393. — Uterus  Cordiformis, 
393. — Uterus  Septus,  393. — Malformation  of  the  Vagina,  393. — Her- 
manhroditism,  395. 

CHAPTER  XXXIV. 
Disorders  of  Menstruation 397 

Amenorrhea,  398. — Acute  Suppression  of  Menstruation,  400. — 
Scanty  Menstruation,  400. — Vicarious  Menstruation,  401. 


CONTENTS.  15 

CHAPTER  XXXV. 

PAGE 

The  Menopause     402 

CHAPTER  XXXVI. 
Genitai<  Fistui<^ 404 

Vesico-vaginal  Fistula,  404. — Urethro-vaginal  Fistula,  412. — Vesico- 
uterine Fistula,  413. — Uretero-vaginal  Fistula,  413. — Recto-vaginal 
Fistula,  413. 

CHAPTER  XXXVII. 
Diseases  of  the  Urethra  and  Bi^adder 416 

Diseases  of  the  Urethra,  419. — Urethritis,  420. — Stricture  of  the 
Urethra,  423. — Prolapse  of  the  Mucous  Membrane  of  the  Urethra, 
424. — Vesico-urethral  Fissure,  424. — Urethral  Neoplasms,  426. — 
Urethral  Caruncle,  426. — Urethral  Cysts,  427. — Polypus,  427. — 
Sarcoma  and  Cancer  of  the  Urethra,  428. — Diseases  of  the  Blad- 
der, 428. — Cystitis,  429. — Vesical  Calculus,  438. 

CHAPTER   XXXVIII. 
Gonorrhea  in  Women 440 

CHAPTER   XXXIX. 
The  Technique  of  Gynecoi,ogicai.  Operations 449 

Apparatus,  454. — Operator,  Assistants,  Nurses,  455. — Sterilization 
of  Dressings,  Towels,  etc.,  458. — Sterilization  of  Instruments,  458. — 
The  Water,  459. — Sponges,  460. — Discipline  of  the  Operating-room, 
461. — Anesthesia,  462. — Preparation  of  the  Patient,  463. — Instruments, 
467.— The  Dressing,  471. 

CHAPTER  XL. 

The   Technique    of    Gynecological    Operations    {Con- 
tinued)   472 

Abdominal  Drainage,  472. — Gauze-drainage,  475. — Indications  for 
Drainage,  476. — Vaginal  Drainage,  479. — The  Incision  of  the  Ab- 
dominal Wall,  479. — Exploration  of  the  Abdomen,  481. — Protec- 
tion of  the  Intestines  and  Omentum,  481. — Toilet  of  the  Peri- 
toneum, 482. — Closing  the  Abdominal  Incision,  483. 

CHAPTER  XLI. 
Treatment  after  Celiotomy - 486 


l6  CONTENTS. 

CHAPTER    XLH. 


PAGE 


The  Special  Technique  of  Operations  upon  the  Uterus 
AND  THE  Uterine  Appendages 494 

Removal  of  the  Uterine  Appendages  (Salpingo-oophorectomy),496. 
— Removal  of  an  Ovarian  Cyst,  503. — Operation  for  the  Removal  of 
Intra-ligamentous  Cysts,  505. — Marsupialization  of  the  Cyst,  507. — 
Operation  for  Removal  of  the  Uterus,  508. — Supra-vaginal  Amputa- 
tion of  the  Uterus,  509. — Complete  Abdominal  Hysterectomy,  514. — 
Vaginal  Hysterectomy,  518. — Combined  Vaginal  and  Abdominal 
Hysterectomy,  522. — Abdominal   Myomectomy,  524. 

CHAPTER   XUII. 

The  Effect  op  the  Removai.  of  the  Uterine  Append- 
ages  525 


A   TEXT-BOOK 

OF 

DISEASES   OF   WOMEN 


CHAPTER    I. 
THE  GENERAL  CAUSES  OF   DISEASES    OF  WOMEN. 

Gynecology  is  the  study  of  diseases  peculiar  to 
women.  As  woman  possesses  organs  which  man  has 
not,  and  as  the  parts — physiological  and  social — that 
she  plays  in  life  differ  from  those  played  by  man,  we 
should  expect  to  find  her  afilicted  with  a  certain  num- 
ber of  diseases,  peculiar  to  her,  which  are  dependent 
upon  her  anatomy,  physiology,  and  mode  of  life.  Such 
diseases  occur  in  barbarous  as  well  as  in  civilized 
women;  and  similar  diseases,  peculiar  to  the  female, 
occur  in  the  lower  animals.  Thus,  in  the  cow  and  the 
mare  we  find  tumors  of  the  vagina,  prolapse  of  the  vagina 
and  uterus,  fibroid  tumors,  sarcoma  and  cancer  of  the 
uterus,  and  some  forms  of  ovarian  cysts.  Cysts  of  the 
tubes  and  the  ovaries  are  exceedingly  commoti  in  old 
mares;  cats  and  goats  are  similarly  aflFected. 

From  a  pathological  point  of  view,  however,  the  civil- 
ized woman  unfortunately  differs  from  her  barbarous 
sister,  and  from  the  female  of  the  lower  animals,  in  many 
important  particulars.  She  is  more  liable  to  the  patho- 
logical conditions  which,  more  or  less,  all  females  have 
in  common.  These  conditions  appear  in  a  more  severe 
form,  and  are  followed  by  more  disastrous  results,  in 
the  civilized  than  in  the  barbarous  state. 

The    female    among    the    lower    animals    and    among 

2  17 


1 8         A   TEXT- BOOK  OF  DISEASES  OF  WOMEN. 

savages  seems  to  be  about  equal  in  proportionate 
strength  and  physical  endurance  to  the  male,  though 
in  size  and  in  gross  muscular  strength  she  may  be  his 
inferior.  Her  subordinate  position  is  often  due  not  so 
much  to  any  difference  in  strength  as  to  the  fact  that 
the  male  possesses  weapons — as  the  horns  of  the  deer 
— with  which  nature  has  not  endowed  the  female;  and 
though  she  is  liable  to  more  diseases  than  the  male, 
yet  her  relative  position  does  not  seem  to  be  materially 
altered  by  this  fact.  The  bitch  is  as  enduring  as  the 
dog.  The  female  grizzly  is  as  ferocious  and  as  danger- 
ous as  the  male.  The  mare  is  as  fast  as  the  horse. 
The  squaw  among  the  American  Indians  can  lift  and 
carry  burdens  which  the  lazy  buck  would  not  attempt. 

How  different  it  is  with  the  civilized  woman,  as  we 
know  her  in  this  country !  The  average  healthy  woman 
in  this  country  is  very  much  inferior  in  physical  strength 
and  endurance  to  the  average  man,  and  this  inferiority 
is  tremendously  increased  when  she  becomes  sick  from 
any  of  the  diseases  to  which  her  sex  is  liable. 

The  increased  liability  of  the  civilized  woman  to  dis- 
ease is  in  a  large  measure  due  to  her  poor  physique. 
But  this  is  not  all. 

The  causes  of  many  of  the  diseases  with  which  the 
gynecologist  has  to  deal  cannot  be  traced  so  easily. 

Fibroid  tumors  of  the  uterus,  which  are  so  common 
among  the  colored  women  of  this  country,  are  said  by 
Tait  to  be  unknown  among  their  African  cousins,  who 
are  removed  by  but  a  few  generations. 

The  most  common  causes  of  diseases  of  women  are 
injuries  received  during  parturition;  sepsis;  venereal  dis- 
eases; errors  of  development;  improper  mode  of  life  and 
clothing  during  the  period  of  development;  neglect  dur- 
ing menstruation;  and  celibacy. 

The  results  of  the  injuries  received  during  parturition 
are  most  numerous.  They  may  appear  immediately,  a 
short  time  after  labor,  or  at  some  remote  period.  The 
disabilities   attending    laceration  through  the    sphincter 


GENERAL  CAUSES  OF  DISEASES  OF  WOMEN.      19 

ani  or  a  recto-vaginal  or  vesico-vaginal  fistula  appear 
before  the  mother  leaves  her  bed.  The  suffering  from 
a  laceration  of  the  cervix,  a  subinvolution  of  the  uterus, 
or  a  retrodisplacement  may  not  be  felt  for  some  weeks 
or  months  after  labor;  while  the  still  more  remote  re- 
sult, the  development  of  cancer,  may  not  appear  for 
many  years,  though  it  can  be  positively  traced  to  the 
lesion  in  the  cervix  as  the  primary  cause. 

Septic  infection  of  the  genital  tract  kills  or  makes 
invalids  of  many  women.  The  infection  occurs  at  the 
time  of  a  miscarriage  or  of  a  normal  labor,  or  it  may  be 
acquired  from  the  dirty  instruments  or  the  dirty  hands 
of  a  physician.  It  is  not  a  cause  of  disease  among  civil- 
ized women  alone,  but  occurs  among  barbarous  and 
semi-barbarous  races. 

Venereal  disease,  especially  gonorrhea,  has  been  said 
to  be  the  most  common  cause  of  disease  among  women. 
The  disease  extends  from  the  external  genitals  through 
the  uterus  and  Fallopian  tubes,  causing  sterility,  chronic 
invalidism,  and  death  from  peritonitis. 

Errors  of  development  are  frequent  causes  of  disease 
and  suffering  among  women.  Atresia  of  the  vagina  or 
of  the  cervix  uteri,  by  causing  retention  of  the  uterine 
discharges,  produces  most  serious  pathological  conditions. 
Arrested  development  of  the  whole  or  of  part  of  the 
uterus  is  a  common  cause  of  disease. 

Improper  clothing  and  an  improper  mode  of  life  dur- 
ing the  period  of  development  are  most  fertile  sources  of 
diseases  of  women.  Clothing  which  contracts  the  waist, 
as  well  as  clothing  which,  though  not  unduly  tight  in 
the  inactive  state,  yet  interferes  with  abdominal  respira- 
tion during  activity,  is  most  injurious.  Such  clothing 
diminishes  the  capacity  of  inspiration  by  restricting  ab- 
dominal expansion,  and  thus  crowds  down  the  pelvic 
organs  toward  the  pelvic  floor;  and  the  continuous  sup- 
port to  the  abdominal  walls  diminishes  their  natural 
muscular  strength  and  places  the  woman  in  a  condition 
predisposing  to  the  various  displacements  of  the  uterus. 


20         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

An  improper  mode  of  life,  irregular  hours  for  sleeping 
and  eating,  insufficient  exercise,  and  lack  of  fresh  air  and 
sun,  resulting  in  poor  muscular  development,  seem  to 
predispose  the  woman,  as  the  man,  to  a  variety  of  patho- 
logical conditions;  but  as  the  reproductive  apparatus  in 
woman  is  more  delicately  organized,  and  as,  during  the 
period  of  active  life,  this  is  really  her  chief  part,  it  more 
especially  suffers  as  a  result  of  any  general  systemic 
derangement. 

Neglect  during  menstruation,  especially  in  the  young 
girl,  is  a  frequent  cause  of  subsequent  suffering.  The 
effect  of  menstruation  upon  the  whole  system  is  remark- 
able. The  nervous,  vascular,  and  digestive  systems  all 
share  in  the  menstrual  function.  The  usual  work  of  the 
girl  at  school  or  other  employment  should  be  altered  to 
suit  the  altered  conditions  of  her  body  at  the  menstrual 
period.  Long  school  hours  and  close  mental  application 
or  active  exercise  are  too  often  continued  at  this  time. 

Celibacy  is  an  unnatural  state  and  a  common  cause  of 
disease.  Certain  forms  of  fibroid  tumors  of  the  uterus 
are  more  common  in  single  than  in  married  women,  and 
more  common  in  sterile  than  in  childbearing  women. 
And  the  painful  cirrhotic  ovaries  of  the  old  maid  are  the 
result  of  the  unceasing  menstrual  congestions  never 
relieved  by  pregnancy  and  lactation. 


CHAPTER    II. 
METHODS  OF  EXAMINATION. 

In  order  to  make  a  complete  gynecological  examina- 
tion, we  must  examine  the  abdomen,  the  external  organs 
of  generation,  and  the  pelvic  structures. 

Bxamination  of  the  Abdomen. — In  order  to  make 
a  perfectly  satisfactory  examination  of  the  abdomen,  the 
woman  should  be  in  bed,  with  all  clothing  removed  ex- 
cept the  undershirt  and  the  night-dress,  which  should  be 
drawn  well  up  above  the  costal  margin.  Examination 
made  with  any  constricting  clothing  about  the  waist  or 
about  the  lower  thorax  is  most  unsatisfactory. 

The  abdomen  is  examined  by  inspection,  palpation, 
percussion,   and  auscultation. 

The  woman  should  lie  flat  upon  her  back,  and  the 
abdomen  should  be  thoroughly  exposed.  We  can  then 
determine  by  inspection  the  presence  of  dilated  veins  or 
of  linese  albicantes,  the  general  size  and  form  of  the 
abdomen,  the  occurrence  of  any  abdominal  movement, 
and  the  presence  of  any  asymmetry  in  the  abdominal 
contour,  such  as  would  be  made  by  the  bulge  of  a  tumor 
or  the  displacement  of  an  abdominal  organ.  The  shape 
of  the  abdomen,  even  though  symmetrical,  is  often  diag- 
nostic of  certain  intra-abdominal  conditions.  Thus,  an 
abdominal  enlargement  that  is  due  merely  to  fat  presents 
a  different  contour  from  the  enlargement  caused  by  tym- 
panitic distention  of  the  intestine.  The  enlargement  due 
to  ascites,  or  free  fluid  in  the  peritoneum,  differs  in  con- 
tour from  that  caused  by  an  encysted  collection  of  fluid. 

It  should  be  remembered  that  linese  albicantes  are  not 
always  the  result  of  pregnancy,  but  that  they  may  have 

21 


22         A   TEXT- BOOK  OF  DISEASES  OF  WOMEN. 

been  caused  by  distention  of  the  abdomen  from  some 
other  cause. 

Palpation. — We  can  determine  most  by  palpation  of 
the  abdomen.  The  examiner  should  always  remember 
that  it  is  most  important  to  secure  the  patient's  con- 
fidence, and  to  proceed  so  gently,  slowly,  and  gradually 
in  performing  palpation  that  no  voluntary  or  reflex  con- 
traction of  the  abdominal  muscles  may  impede  his  ma- 
nipulations. 

In  cases  in  which  there  is  a  sore  or  tender  spot  within 
the  abdomen  the  contraction  of  the  recti  muscles  may  be 
altogether  involuntary,  persisting  even  when  the  patient 
is  anesthetized.  We  see  this  in  the  rigid  right  rectus 
muscle  of  appendicitis.  The  hands  should  be  warmed, 
and  palpation  should  be  performed  with  both  hands.  A 
certain  amount  of  gentle  stroking  or  massage  of  the 
abdomen  will  secure  the  patient's  confidence  by  making 
her  feel  that  she  will  not  be  hurt  by  any  sudden  violent 
pressure,  and  will  also  prevent  reflex  contraction  of  the 
muscles.  By  proceeding  in  this  way,  slowly,  the  exam- 
iner can  palpate  the  whole  of  the  abdominal  surface, 
exploring  first  the  structures  lying  most  anterior,  and 
then,  pressing  the  fingers  more  deeply,  he  can  examine 
the  more  posterior  structures. 

Fluctuation  in  an  encysted  fluid  accumulation  is  gen- 
erally readily  determined.  While  one  hand  is  placed 
against  one  side  of  the  fluid  mass  and  the  opposite  side 
is  percussed  by  the .  fingers  of  the  other  hand,  the  wave 
of  fluctuation  is  easily  felt.  Sometimes  a  thrill  or  a  false 
wave  of  fluctuation  is  observed  in  the  subcutaneous  fat 
of  obese  women.  This  disturbing  element  may,  how- 
ever, be  eliminated  by  an  assistant  pressing  the  ulnar 
edge  of  his  hand  in  the  median  line  upon  the  abdominal 
surface,  thus  stopping  the  fat  wave  of  fluctuation. 

Special  organs  in  the  abdomen  sometimes  require 
special  methods  of  examination.  It  is  very  often  neces- 
sary for  the  gynecologist  to  examine  the  kidneys,  because 
many  women  have  movable  or  floating  kidneys,  and  the 


ME  THODS  OF  EX  AM  IN  A  TION.  23 

nervous,  gastric,  and  abdominal  symptoms  may  be  due 
to  this  condition.  The  presence  of  a  floating  kidney 
may  often  be  determined  by  inspection;  the  presence  of  a 
movable  kidney,  however,  must  be  determined  by  palpa- 
tion. This  should  be  performed  with  the  woman  in  the 
sitting,  or  standing,  erect  posture;  or  sitting  upon  the 
edge  of  a  chair,  with  the  body  inclined  somewhat  for- 
ward and  the  hands  upon  the  knees;  or  lying  upon  a  bed, 
on  the  side  opposite  the  kidney  that  is  being  examined. 
One  hand  should  be  placed  over  the  lumbar  muscles;  the 
other  hand  should  be  placed  upon  the  anterior  abdominal 
wall  immediately  below  the  costal  margin,  and  should 
be  pressed  backward.  If  the  kidney  lies  below  its  nor- 
mal position,  it  may  in  this  way  be  brought  between  the 
two  hands,  and  can  be  felt  to  glide  upward  as  the  hands 
are  pressed  together.  In  case  a  movable  kidney  cannot 
readily  be  found,  because  it  may  have  returned  to  its 
normal  position,  it  may  often  be  brought  down  again  if 
the  woman  is  made  to  cough. 

In  a  thin  woman  the  vermiform  appendix  may  some- 
times be  felt  through  the  abdominal  wall;  and  in  cases 
of  pain  and  inflammation  in  the  right  iliac  region  it  is 
sometimes  important  to  determine  whether  or  not  the 
trouble  has  started  in  the  vermiform  appendix  or  in  the 
Fallopian  tube.  In  order  to  palpate  the  vermiform  ap- 
pendix the  examiner  should  stand  upon  the  right  side 
of  the  woman,  who  is  lying  upon  her  back,  and  should 
place  the  tips  of  the  fingers  of  the  right  hand  at  about 
the  junction  of  the  upper  and  middle  thirds  of  a  line 
drawn  from  the  middle  of  Poupart's  ligament  to  the  um- 
bilicus. By  pressing  backward  firmly  and  gently,  pul- 
sations of  the  right  common  iliac  artery  may  be  felt; 
and  then  by  drawing  the  hand  directly  outward  it  will 
pass  over  the  different  structures  in  this  region  lying 
between  the  palpating  hand  and  the  posterior  abdom- 
inal wall.  The  appendix  may  often  be  felt,  especially 
if  it  is  indurated  by  inflammation. 

Percussion  of  the  abdomen  should  be  performed  with 


24         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

the  woman  in  the  dorsal  position;  though,  if  the  exam- 
iner suspects  the  presence  of  free  fluid  in  the  peritoneum, 
or  ascites,  much  may  be  learned  by  percussing  in  differ- 
ent positions  and  noting  the  accompanying  changes  in 
the  percussion-note. 

Percussion  should  then  be  performed  with  the  woman 
upon  her  back,  upon  the  right  side,  upon  the  left  side, 
sitting  up,  and  upon  the  hands  and  knees.  An  encysted 
fluid  accumulation  will  give  practically  the  same  result 
in  percussion  in  all  positions,  while  free  fluid  will  gravi- 
tate to  the  most  dependent  portion. 

Auscultation  of  the  abdomen  is  best  performed  with 
the  stethoscope.  By  it  we  may  hear  fetal  heart-sounds, 
uterine  souffle,  placental  bruit,  peritoneal  friction  sounds, 
and  the  peristaltic  sounds  of  the  intestinal  tract.  All 
of  these  sounds  are  of  importance,  and  the  presence  or 
absence  of  any  of  them  may  have  an  important  bearing 
upon  the  diagnosis  of  the  case. 

Kxatnination  of  Bxtemal  Genitals  and  Pelvic 
Structures. — To  examine  the  external  organs  of  genera- 
tion and  the  pelvic  viscera  the  woman  should  be  placed 
upon  a  table.  In  some  cases  the  physician  may  be 
obliged,  for  want  of  proper  facilities  or  on  account  of 
the  physical  condition  of  the  patient,  to  make  his  ex- 
amination upon  a  bed.  Such  an  examination,  however, 
is  never  so  satisfactory  or  so  thorough  as  the  examina- 
tion made  with  the  woman  upon  the  examining-table. 
A  great  number  of  gynecological  tables  have  been  intro- 
duced. The  one  which  seems  to  the  writer  the  best,  on 
account  of  its  simplicity  and  the  perfect  relaxation  of 
the  abdominal  muscles  furnished  by  it,  is  shown  in  the 
accompanying  illustration  (Fig.  i).  It  is  a  plain  wooden 
table,  at  the  foot  of  which  are  attached  the  upright  sup- 
ports for  holding  the  stirrups  for  the  feet,  such  as  have 
"been  devised  by  Dr.  Edebohls.  By  this  arrangement  the 
feet  and  legs  are  supported  without  any  effort  on  the  part 
of  the  woman;  when  the  buttocks  are  drawn  well  down 
to  the  foot  of  the  table  there  is  a  certain  amount  of  flexion 


METHODS  OF  EX  A  MI N A  TION. 


25 


of  the  pelvis  upon  the   trunk,   and   the   most   complete 
attainable  relaxation  of  the  abdominal  muscles  is  secured. 

When  the  woman  has  been  placed  in  this  position  the 
examiner  should  investigate  thoroughly,  and  in  order,  the 
following  structures:  The  anus,  the  perineum,  the  labia 
majora,  the  nymphse,  the 
fourchette,  the  orifices  of 
the  ducts  of  the  vulvo- 
vaginal glands,  the  hymen 
or  its  remains,  the  vestibule 
and  the  small  glands  of  the 
vestibule,  the  external  uri- 
nary meatus,  and  the  clit- 
oris. 

To  determine  any  patho- 
logical condition  of  these 
structures  it  is  necessary 
that  the  physician  should 
be  familiar  with  the  appear- 
ance in  the  normal  woman, 
and  to  gain  such  essential 
knowledge  we  should  avail 
ourselves  of  every  opportu- 
nity offered  to  make  a  criti- 
cal examination  of  the  external  genitals  of  women,  going 
.over  all  the  different  structures  in  order. 

Vaginal  and  Bimanual  l^xamination. — Having  ex- 
;amined  and  noted  the  condition  of  the  external  genitals, 
the  physician  should  next  proceed  to  examine  the  va- 
;gina.  The  index  finger  of  the  right  or  the  left  hand 
■should  be  gently  introduced  into  the  vagina.  The  con- 
•dition  of  the  vaginal  walls,  and  the  direction,  consist- 
■ency,  form,  etc.  of  the  vaginal  cervix,  may  be  deter- 
mined. The  shape  and  size  of  the  os  uteri  should  be  noted. 
The  ulnar  edge  and  the  tips  of  the  fingers  of  the  other 
hand  should  then  be  placed  upon  the  abdomen,  immedi- 
ately above  the  symphysis  pubis,  and  gently  pressed 
'backward    and    downward    toward    the   vaginal    finger 


Fig.  I. — Woman  in  the  dorsal  po- 
sition with  feet  supported  in  Edebohls' 
stirrups. 


26         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

(Fig.  2).  In  this  way  the  various  pelvic  organs,  the 
uterus,  Fallopian  tubes,  ovaries,  and  ureters,  may  be 
palpated   between    the   two   hands,    and    their   position, 


^.^^^^^ 


Fig.  2. — Bimanual  examination. 


size,  shape,  and  consistency  may  be  determined.  Such 
an  examination  is,  of  course,  made  much  more  easily 
in  a  thin  woman  than  in  a  fat  one.  A  thin  woman  a 
few  weeks  after  labor  may  be  examined  most  easily,  on 
account  of  the  relaxation  of  the  abdominal  and  vagfinal 
walls. 

This  is  called  the  bimanual  method  of  examination, 
and  the  student  will  find  that  as  he  acquires  practice  in 
this  method  he  will  gradually  depend  less  upon  examina- 
tion by  the  uterine  sound  and  the  speculum,  and  will 
rely  altogether  upon  his  sense  of  touch,  his  ability  to 
palpate. 

It  matters  not  which  hand  be  used  in  making  the  vag- 
inal examination.  It  will,  however,  be  found  that  the 
hand  that  is  used  the  more  frequently  will  become  the 
more  proficient. 

In   making-  the  bimanual  examination  the  structures 


METHODS  OF  EX  AM  IN  A  TION. 


27 


should  be  palpated  methodically  in  order.  The  vaginal 
finger  notes  the  condition  of  the  cervix  uteri.  If  the 
fundus  be  in  the  normal  position,  the  uterus  can  then  be 
taken  between  the  abdominal  hand  (upon  the  fundus)  and 
the  vaginal  finger  (upon  the  cervix)  (Fig.  3).     The  shape, 


Fig.  3. — Bimanual  examination;  median  sagittal  section  of  the  pelvis. 


size,  mobility,  and  consistency  are  noted.  The  vaginal 
finger  is  then  passed  anteriorly  and  laterally  toward  either 
uterine  cornu,  while  the  abdominal  fingers  pass  over  to 
the  posterior  aspect  of  the  same  cornu.  The  ovarian 
ligament  and  the  proximal  end  of  the  Fallopian  tube 
may  thus  be  felt.  Passing  farther  outward,  the  whole  of 
the  tube  and  the  ovary  may  be  examined.  The  same 
procedure  is  then  applied  to  the  opposite  side. 

The  condition  of  the  ureters  may  be  determined  by 
placing  the  vaginal  finger  in  either  lateral  vaginal  fornix 
and  drawing  it  outward  and  forward,  when  these  struc- 
tures will  pass  over  the  end  of  the  finger.     When  the 


28         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

ureters  are  indurated  by  inflammation  they  can  be  plainly 
felt. 

By  the  method  of  examination  here  advised  the  physi- 
cian will  always  make  a  visual  examination  before  mak- 
ing a  disfital  one.  There  are  several  advantages  derived 
from  this  procedure.  In  the  first  place,  no  examination 
of  a  woman  is  thorough  unless  a  careful  visual  examina- 
tion of  the  external  genitals  has  been  made.  The  discov- 
ery of  discharges  and  of  lesions  of  the  external  genitals 
may  throw  much  light  upon  the  condition  found  higher  up 
in  the  pelvis.  Again,  the  examiner  protects  himself  A 
great  many  unfortunate  cases  of  syphilis  have  been  ac- 
quired by  physicians  from  a  primary  sore  upon  the  exam- 
ining finger.  A  preliminary  visual  examination  enables 
one  to  guard  against  this  danger.  The  primary  sore 
occurs  upon  the  end  of  the  examining  finger  or  upon  the 
web  between  the  index  and  middle  fingers — the  part  of 
the  hand  that  is  pressed  against  the  fourchette. 

The  hands  of  the  physician  should,  of  course,  be  clean 
before  making  an  examination,  and  the  grease  or  oil 
which  is  used  as  a  lubricant  should  be  clean.  The  hands 
should  always  be  washed,  after  separating  the  parts  to 
make  the  visual  examination,  before  the  finger  is  thrust 
into  the  vessel  containing  the  lubricant.  It  is  best  to 
place  a  small  portion  of  the  lubricant  on  a  plate  or  a 
saucer  for  each  individual  patient,  and  thus  avoid  the 
danger  of  contaminating  the  rest.  Carbolized  oil,  borated 
vaseline  or  cosmoline,  and  a  thick  sterile  solution  of  soap 
are  good  lubricants.  Neutral  green  soap  diluted  with 
boiled  water  to  the  consistency  of  thin  jelly  is  a  very 
agreeable  lubricant  which  may  easily  be  washed  from  the 
hands  and  the  vagina. 

If  practicable,  the  woman  should  receive  a  vaginal 
douche  of  bichloride-of-mercury  solution,  i  :  4000,  and 
the  vulva  should  be  washed,  before  making  a  biman- 
ual examination.  The  examiner  should  always  clean  the 
external  genitals  of  all  discharges  before  introducing  the 
vaginal  finger.      In  this  way  we  avoid  the  danger  of 


METHODS  OF  EXAMINA  TION. 


29 


carrying  septic  material  from  the  external  genitals  to  the 
upper  portion  of  the  genital  tract.  This  preliminary 
cleansing  is  not  desirable  before  the  external  genitals 
have  been  examined;  for  much  may  be  learned  from 
observation  of  the  discharges  which  bathe  or  escape  from 
the  various  structures.  If  practicable,  a  cleansing  vaginal 
douche  of  bichloride-of-mercury  solution  should  be  admin- 
istered after  the  bimanual  examination. 

The  examination  of  the  uterus  and  other  pelvic  struc- 
tures is  often  facilitated  by  dragging  the  uterus  downward 
with  a  tenaculum  while  the  vaginal  or  the  bimanual 
examination  is  being  made.  Sensation  in  the  cervix  is 
so  slight  that  little  or  no  pain  is  experienced  in  this  pro- 
cedure. The  anterior  or  posterior  lip  of  the  cervix  is 
caught  with  the  single  or  the  double  tenaculum  (Fig.  4), 


Fig.  4. — Double  tenaculum. 


guided  along  the  vaginal  finger  or  introduced  through 
the  speculum,  and  the  uterus  is  drawn  down  by  an  assist- 
ant in  case  the  bimanual  examination  is  being  made,  or 
by  the  external  hand  of  the  examiner  in  case  a  simple  vag- 
inal examination  is  made.  When  this  is  done  the  utero- 
sacral  ligaments  are  made  tense,  and  can  be  felt  like  two 
cords  extending  from  the  sides  of  the  cervix  outward  and 
backward  to  the  pelvic  wall.  The  posterior  surface  of 
the  uterus  can  be  palpated  often  as  high  up  as  the  fundus. 
The  method  is  especially  useful  when  the  examination  is 
made  by  the  rectum,  and  in  this  way  the  whole  posterior 
surface  and  the  fundus  of  the  uterus  may  be  palpated 

(Fig-  5)- 

The    contraindications  to   a  vaginal  examination  are 


30         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

virginity,  the  presence  of  a  hymen,  and  any  acute  in- 
flammatory or  painful  condition  of  the  vulva  or  vagina. 
None  of  these  conditions,  however,  forbid  an  examina- 
tion if  an  exact  diagnosis  is  essential  to  the  proper  treat- 
ment of  the  case,  and  can  be  made  only  in  this  way.     It 


P"lG.  5- — Bimanual  examination  with  one  nnger  in  the  rectum.     Tlie  uterus  is 
drawn  down  witii  the  double  tenaculum. 

may  be  that  in  these  cases  a  rectal  examination  will  be 
sufficient  for  diagnosis. 

Rectal  examination  of  the  pelvic  structures  is  made  in 
a  way  similar  to  that  already  described  for  the  vaginal 
examination.  Bimanual  examination  may  be  made  by 
palpating  the  various  organs  between  the  rectal  finger 
and  the  abdominal  hand. 

The  Vaginal  Speculum,. — The  speculum  is  an  instru- 
ment through  which  a  visual  examination  is  made  of  the 
vagina,  the  external  os  uteri,  and  the  vaginal  cervix.     A 


METHODS  OF  EX  AM/N  A  TION. 


31 


great  number  of  specula  have  been  invented.  At  the 
present  day  the  best  two  instruments  of  this  class  are 
the  bivalve  speculum,  such  as   Goodell's  (Fig.   6),  and 


Fig.  6. — Goodell's  speculum. 


the  duck-bill  speculum  (Fig.    7),   or  perineal  retractor, 
invented  by  Sims. 


Fig.  7. — Sims'  speculum. 

The  bivalve  speculum  is  introduced  with  the  woman 
upon  her  back,  in  the  dorso-sacral  position  already  de- 


FiG.  8. — Sims'  depressor  for  the  anterior  vaginal  wall. 

scribed.  The  vulva  and  the  vagina  should  be  cleaned. 
The  speculum  should  be  warmed  by  placing  it  in  hot 
water,  and  should  then  be  lubricated  with  the  soap  solu- 
tion or  with  vaseline.  It  should  be  introduced  with  the 
blades  closed  and  the  plane  of  the  blades  lying  not  ex- 


32 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


actly  in  the  median  sagittal  plane  of  the  body,  but  in- 
clined at  a  small  acute  angle  to  this  plane,  one  edge  of  the 
speculum  being  directed  toward  either  vaginal  sulcus. 
The  instrument  is  passed  into  the  vagina  toward  the  posi- 
tion in  which,  by  a  previous  digital  examination,  the  vag- 
inal cervix  had  been  found  to  lie.  The  instrument  is  then 
turned  with  the  handles  toward  either  thigh,  so  that  the 
blades  become  parallel  to  the  anterior  and  posterior  vag- 
inal walls,  in  order  that,  when  separated,  they  will  open 
the  vaginal  slit.     The  handles  are  brought  together  and 


Fig.  9. — Goodell's  speculum  in  position. 

the   blades    opened.     When   the   vaginal   cervix   comes 
well  into  view  the  blades  are  fixed  in  place  by  the  screws 

(I^ig-  9)- 

In  some  cases,  where  the  cervix  points  well  forward 
or  well  backward,  it  may  be  readily  brought  into  view 
through  the  speculum  by  catching  it  with  a  tenaculum. 

By  means  of  the  bivalve  speculum  we  are  able  to  make 
a  partial  inspection  of  the  vaginal  walls,  an  imperfect 
inspection  of  the  vaginal  vault,  and  a  good  inspection 
of  the  vaginal  cervix  and  the  external  os.     Applications 


ME  THODS  OF  EX  AM/N  A  TION. 


33 


can  be  made  to  the  cervix,  but  none  of  the  minor  ope- 
rations of  gynecology  can  be  performed  through  this 
speculum. 

The  Sims  speculum  enables  us  to  make  the  most  thor- 
ough inspection  of  the  vagina,  the  vaginal  vault,  and  the 
vaginal  cervix.  The  Sims  speculum  is  merely  a  hook  or 
retractor  for  the  perineum,  and  may  be  introduced  with 
the  woman  in  the  dorsal  position,  the  Sims  position,  or 
the  genu-pectoral  position.  If  the  Sims  speculum  is 
introduced  in  the  dorso-sacral  position,    it  is  necessary 


Fig.  io. — The  Sims  position. 


to  hold  forward    the  anterior  vaginal  wall  in  order  to 
obtain  a  view  of  the  cervix. 

The  Sims  position,  which  is  also  called  the  latero- 
abdominal  position,  is  shown  in  Fig.  lo.  The  woman 
is  placed  on  the  bed  or  table  upon  her  left  side.  The 
side  of  the  face  is  upon  the  pillow;  the  left  arm  is  behind 
the  back,  so  that  the  left  breast  rests  upon  the  table. 
The  thighs  are  flexed  upon  the  abdomen  at  an  angle  of 
about  90°  to  the  trunk.  The  right  thigh  is  more  flexed 
than  the  left,  so  that  the  right  knee  may  touch  the  table 
above  the  left  knee.  The  legs  are  flexed  on  the  thighs. 
In  this  position  there  is  a  tendency  for  the  intestines, 
following  the  force  of  gravity,  to  fall  from  the  pelvis, 


34         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

and  for  the  uterus  and  other  pelvic  viscera  to  be  drawn 
up.  When  the  perineum  is  retracted  with  the  blade  of 
the  Sims  speculum,  air  will  enter  the  vagina  and  the 
vaginal  slit  will  become  distended  (Fig.  ii).     To  facili- 


FlG.  II. — The  cervix  uteri  exposed  with  the  Sims  speculum. 

tate  inspection  of  the  cervix  it  is  usually  necessary  also 
to  push  forward  the  anterior  abdominal  wall  by  some 
kind  of  depressor,  such  as  the  one  shown  in  Fig.  8. 


Fig.  12. — The  knee-chest  position 


The  genu-pectoral  position  or  the  knee-chest  position  is 
shown  in  Fig.  i2.  The  side  of  the  face  is  upon  the  pillow; 
the  breast  is  upon  the  table;  the  thighs  are  vertical.     In 


METHODS  OF  EXAMINATION. 


35 


this  position  the  intestines  fall  from  the  pelvis,  and  the 
other  pelvic  viscera  are  drawn  upward  by  the  force  of 
gravity.  If  the  anus  is  opened,  air  rushes  in  and  dis- 
tends the  rectum.  If  the  perineum  is  retracted,  air 
enters  and  distends  the  vagina.  If  the  urethra  is  opened, 
the  bladder  is  likewise  distended.  The  position  is  the 
most  useful  one  for  inspection  of  the  rectum,  vagina  and 
vaginal  cervix,  and  the  bladder. 

The  Sims  speculum,  with  the  woman  in  the  dorsal,  the 
Sims,  or  the  knee-chest  position,  is  the  most  useful  in- 
strument by  which  to  expose  the  cervix  uteri  for  any  of 
the  minor  operations  of  gynecology.  The  manipulations 
of  the  operator  are  not  hampered  by  working  between 
metal  walls. 

Bxamination  of  the  Rectum. — If  the  woman  is 
placed  in  the  knee-chest  position,  a  most  satisfactory 
inspection  of  the  whole  of  the  rectum  may  be  made. 
The  woman  should  be  placed  in  this  position  with  the 
buttocks  before  a  good  light,  and  the  posterior  margin 
of  the  anus  should  be  retracted  by  the  small  blade  of  a 


Fig.  13. — Rectal  speculum,  large  size.     Fig.  14. — Rectal  speculum,  small  size 


Sims  speculum;  the  rectum  will  immediately  become 
distended  with  air  and  the  rectal  walls  will  be  well  ex- 
posed. Or  the  rectal  specula  (Figs.  13,  14)  may  be  used. 
In  employing  the  longer  of  these  instruments  it  is  best 
to  use  light  reflected  from  a  head-mirror  or  thrown 
directly  from  an  electric  head-light  into  the  speculum. 
The  instrument  should  always  be  introduced  for  the 


36 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


first  two  inches  with  the  obturator  in  place.  The  obtu- 
rator should  then  be  withdrawn  and  the  speculum  pushed 
farther  in,  the  operator  watching  and  guiding  its  course 
around  the  rectal  valves  or  folds  of  mucous  membrane, 
so  as  to  prevent  injury  to  the  walls  of 
the  rectum.  Anesthesia  is  not  neces- 
sary for  this  procedure. 
[Examination  of  the  Bladder. — It 
will  readily  be  understood  that  all  the  hol- 
low viscera  are  much  more  easily  examined 
when  their  walls  are  separated  by  distention 
with  air  than  when  the  walls  are  collapsed. 
The  bladder  is  most  readily  examined  in 
this  way.  The  woman  should  be  placed 
in  the  knee-chest  position,  or  in  the  dorsal 
position  with  the  hips  elevated  above  the 
abdomen.  In  either  position  the  intestines 
fall  from  the  pelvis,  and  when  the  urethra 
is  opened  air  enters  and  distends  the  blad- 
der. This  distention  is  most  certainly  ac- 
complished in  the  knee-chest  position.  In 
women  who  are  not  very  fat,  however,  the 
extreme  dorso-sacral  position  is  equally  good. 
The  details  of  this  method  of  examination 
are  described  on  a  later  page. 

The  uterine   sound  is    an    instrument    by 

which  the  length  of  the  uterine  cavity  may 

be  determined  (Fig.  15).     The  sound,  which 

is  a  large  surgical  probe,  somewhat  curved 

to  adapt  itself  to  the  normal  shape  of  the 

uterine   axis,  is   made  of  pliable  metal,  so 

that  the  curvature  may  be  changed  readily 

to  suit  any  case.     The  sound  is  graduated, 

and  at  a  position  of  2^  inches  from  the  tip  is  a  small 

elevation   marking   the   length   of    the    normal   uterine 

cavity. 

The  uterine  sound  was  at  one  time  used  a  great  deal  to 
determine  the  length  and  direction  of  the  uterus,   and 


Fig.  15. — Ute- 
rine sound. 


METHODS  OF  EXAMINATION.  37 

perhaps  to  assist  in  determining  the  character  of  the 
uterine  contents  or  of  the  endometrium.  With  our 
present  methods  of  examination,  however,  the  sound  is 
of  but  little  if  any  use.  The  size  and  direction  of  the 
uterus  can  in  nearly  all  cases  be  determined  by  bimanual 
examination.  The  use  of  the  uterine  sound  is  by  no 
means  free  from  danger.  Many  cases  of  septic  endo- 
metritis and  salpingitis  have  been  caused  by  it,  and  the 
physician  has  often  unintentionally  committed  an  abor- 
tion by  passing  the  sound  in  a  pregnant  woman.  The 
uterine  sound  should  never  be  used  in  a  routine  way.  It 
should  never  be  used  unless  one  expects  to  determine 
with  it  something  that  cannot  be  determined  by  simpler 
methods  of  examination. 

The  most  thorough  aseptic  precautions  should  be  ob- 
served when  the  sound  is  introduced.  The  vulva,  vagina, 
and  cervix  should  be  cleaned  and  the  sound  should  be 
sterilized.  The  sound  should  never  be  introduced  if 
there  is  any  suspicion  of  pregnancy. 


CHAPTER   III. 
DISEASES  OF  THE  EXTERNAL  GENITALS. 

Vulvitis. — Vulvitis,  or  inflammation  of  the  vulva,  is 
not  a  common  disease.  The  vulva  is  composed  of  several 
parts  which  are  anatomically  distinct,  and,  though  all 
these  parts  are  usually  involved  in  an  acute  attack  of 
inflammation  of  the  vulva,  yet  the  symptoms  of  the  dis- 
ease and  the  pathological  appearance  depend  to  a  great 
extent  upon  the  structures  which  are  principally  affected. 
The  labia  majora,  the  nymphse,  the  vestibule  with  its 
mucous  crypts  or  glands,  the  clitoris,  the  external  uri- 
nary meatus,  and  the  ducts  of  Bartholin's  glands  may  all 
be  involved  in  the  inflammation.  The  sebaceous  glands 
of  the  labia  may  be  especially  involved,  producing  a  form 
of  sebaceous  acne  which  has  been  called  follicular  vul- 
vitis.    Inguinal  adenitis  may  accompany  vulvitis. 

The  appearance  of  the  parts  is  that  characteristic  of  in- 
flammation of  the  skin  and  mucous  membrane  in  any 
other  part  of  the  body.  The  mucous  membrane  becomes 
red  and  swollen;  the  labia  may  become  edematous;  an 
abundant  purulent  discharge  covers  the  parts,  and  unless 
cleanliness  is  practised  the  irritation  from  the  discharge 
spreads  to  the  inner  aspects  of  the  thighs,  the  perineum, 
and  the  anal  region. 

The  patient  suffers  with  local  pain,  which  is  increased 
by  walking  and  by  the  passage  or  contact  of  urine. 

The  usual  cause  of  vulvitis  is  gonorrhea.  The  con- 
dition is  sometimes  secondary  to  other  diseases.  It  may 
be  caused  by  the  irritation  from  the  discharges  of  a 
vesico-vaginal  or  recto-vaginal  fistula,  from  a  cancer  of 
the  cervix  or  in  some  forms  of  endometritis.     Girls  and 

38 


DISEASES  OF  THE  EXTERNAL  GENITALS.       39 

women  who  are  unclean  may  be  attacked  by  vulvitis  as  a 
result  of  irritation  from  decomposed  smegma,  sweat, 
urine,  etc.  The  oxyuris,  or  thread-worm,  may  enter  the 
vulva  from  the  rectum  and  cause,  in  unclean  children, 
sufficient  irritation  to  produce  inflammation.  Vulvitis 
from  uncleanliness  is  most  likely  to  occur  in  hot  weather 
after  prolonged  exercise.  It  not  infrequently  attacks 
children,  especially  those  of  a  strumous  diathesis,  whose 
hygienic  surroundings  are  poor.  In  such  cases  the  sus- 
picions of  the  parents  may  demand  a  medico-legal  exam- 
ination; and  it  is  of  importance  to  remember  that  vul- 
vitis of  this  kind  is  not  rare,  and  is  not  due  to  violation 
or  contagion.  Vulvitis  in  little  girls  may  be  also  due  to 
gonorrhea,  independently  of  violation.  This  is  the  cause 
of  epidemics  of  vulvitis  and  vaginitis  in  girls  crowded  in 
houses,  hospitals,  or  asylums.  The  disease  is  spread  by 
contamination  from  towels  or  bed-clothing. 

The  essential  points  of  treatment  to  observe  in  the 
acute  stage  of  vulvitis  are  rest  in  the  recumbent  posture 
and  perfect  cleanliness.  The  labia  should  be  separated 
and  the  parts  frequently  bathed  and  cleaned  with  warm 
water.  Various  local  washes  or  applications  are  of  use. 
A  warm  solution  of  boracic  acid  (3J  to  a  pint  of  water), 
the  dilute  solution  of  the  subacetate  of  lead,  or  a  solution 
of  bichloride  of  mercury  (i  :  5000)  may  be  used. 

If  the  disease  is  of  gonorrheal  origin,  the  parts  should 
be  painted  once  or  twice  a  day  with  a  2  per  cent,  solution 
of  nitrate  of  silver,  applied  after  the  discharges  have 
been  gently  washed  away. 

As  the  disease  subsides  the  inflammation  may  be  found 
to  persist  in  the  crypts  of  the  vestibule,  the  urinary 
meatus,  and  the  ducts  of  Bartholin's  glands.  It  is  very 
important  that  all  remains  of  the  inflammation,  especially 
if  it  be  of  septic  or  gonorrheal  origin,  should  be  eradi- 
cated before  the  woman  is  discharged  from  treatment. 
The  presence  of  any  focus  of  inflammation,  even  though 
latent,  is  a  constant  source  of  danger  to  the  woman ;  for  sep- 
tic organisms  or  material  may  be  carried  from  the  external 


40 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


genitals  to  the  higher  parts  of  the  genital  tract,  as  the  uterus 
and  Fallopian  tubes,  with  the  most  disastrous  results. 

Sometimes  a  small  drop  of  pus  will  be  observed  escap- 
ing from  one  of  the  small  glands  or  crypts  of  the  vesti- 
bule, about  the  urinary  meatus,  after  the  inflammation 
has  disappeared  in  other  parts  of  the  vulva.  In  this  case 
the  gland  should  be  punctured  with  a  fine  cautery-point 
or  a  fine  wooden  probe  or  point  saturated  with  pure  car- 
bolic acid  or  other  caustic. 

If  the  disease  persists  in  the  external  meatus  or  urethra, 
it  must  be  treated  by  the  local  applications  appropriate 
for  urethritis. 

Inflammation  of  the  Vulvo-vaginal  Glands. — The 
vulvo-vaginal   glands   are    two   in    number.      They    are 


I'l.m. 


Cm. 


Fig.  i6. — Appearance  of   the  external  genitals  in  a  woman  with  gonorrhea: 
G.  m.,  gonorrheal  macula  situated  at  the  base  of  a  vaginal  caruncle. 

about  the  size  of  a  bean,  and  are  situated  deeply  on  the 
inner  aspect  of  the  labia  majora,  where  they  may  be 
felt  in  thin  women.     The  duct  of  the  o-land  is  about  one 


DISEASES  OF  THE  EXTERNAL  GENITALS.       41 

inch  in  length,  and  opens  immediately  in  front  of  the 
hymen,  about  the  middle  of  the  side  of  the  ostium 
vaginae.  In  cases  of  vulvitis  the  duct  of  the  gland 
usually  becomes  inflamed,  and  the  inflammation  may 
extend  to  the  gland,  producing  abscess  of  the  vulvo-vag- 
inal  gland. 

Inflammation  of  the  duct  and  the  gland  may  also  occur 
independently  of  vulvitis,  from  direct  septic  or  gonorrheal 
infection. 

Suppuration  of  the  duct  may  be  demonstrated  by  press- 
ing over  the  course  of  the  duct,  when  a  drop  of  pus  will 
escape  from  the  opening.  In  such  cases  the  orifice  of 
the  duct  is  usually  surrounded  by  a  red  areola,  resembling 
a  flea-bite,  which  has  been  called  the  gonorrheal  macula 
(Fig.  16).  This  macula  persists  long  after  all  other  traces 
of  inflammation  about  the  vulva  and  vagina  have  dis- 
appeared, and  after  all  frank  suppuration  in  the  duct  has 
subsided.  Its  presence  indicates  at  least  the  probability 
of  previous  gonorrheal  infection. 

When  the  duct  of  the  gland  alone  is  the  seat  of  inflam- 
mation, it  should  be  laid  open  with  fine  scissors  or  knife, 
.and  the  tract  thoroughly  cauterized  with  the  nitrate-of- 
silver  stick,  pure  carbolic  acid,  or  a  solution  of  chloride 
of  zinc  (2  per  cent.). 

Suppuration  of  the  vulvo -vaginal  gland  is  accom- 
panied by  marked  swelling  and  peripheral  edema.  The 
:swelling  may  extend  to  the  anus,  and  is  of  characteristic 
shape  (Fig.  17).  The  pain  is  always  severe.  Fluctua- 
tion is  first  apparent  on  the  inner  surface  of  the  labium 
majus.  If  the  condition  is  not  treated,  one  or  more 
•fistulous  openings  appear  below  the  orifice  of  the  duct, 
and  the  pus  is  discharged.  The  condition  then  becomes 
chronic.  The  fistulous  openings  persist.  Acute  inflam- 
mation disappears  from  the  gland,  leaving  it  in  a  con- 
•dition  of  hypertrophic  induration.  A  thin,  milky  or 
greenish,  purulent  fluid  may  be  pressed  out  of  the  duct 
•or  the  fistulous  openings.  Infection  from  this  discharge 
:may  be  communicated  to  man,  or  may  ascend  the  genital 


42 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


tract,  producing  inflammation  of  the  endometrium  or  of 
the  Fallopian  tubes. 

In  abscess  of  the  vulvo- vaginal  gland  a  free  incision 
should  immediately  be  made  into  the  labium  at  the  junc- 
tion of  the  skin  and  the  mucous  membrane.  The  interior 
should  be  wiped  out  with  pure  carbolic  acid  and  the  cav- 


FiG.  17 


ity  packed  with  gauze.  If  the  disease  is  first  seen  in  the 
chronic  stage,  after  the  abscess  has  evacuated  itself,  the 
only  method  of  cure  is  to  excise,  with  curved  scissors, 
the  whole  of  the  indurated  gland,  the  duct,  and  the  fis- 
tulous tracts.  The  wound  may  be  left  open  and  packed, 
or  it  may  be  closed  immediately  with  buried  catgut 
sutures. 
Cysts   of  the  Vulvo-vaginal   Glands. — Cysts  may 


DISEASES  OF  THE  EXTERNAL  GENITALS.       43 

occur  in  the  duct  of  the  vulvo-vaginal  gland  or  in  the 
gland  itself.  Cysts  of  the  duct  are  small — about  the  size 
of  a  chestnut.  They  are  situated  superficially,  lying 
immediately  under  the '  mucous  membrane  of  the  vagina 
at  tl]e  base  of  the  labium  minus. 


Fig.  18. — Cyst  of  the  right  vulvo-vaginal  gland  (Hirst). 

Cysts  of  the  gland  may  be  unilocular  if  formed  at  the 
expense  of  a  single  lobule  of  the  gland,  or  multilocular 
if  several  lobules  enter  into  their  formation.  These  cysts 
may  attain  the  size  of  the  fetal  head  (Fig.  18). 

Cysts  of  the  gland  or  of  the  duct  are  formed  by  reten- 
tion of  the  cyst-contents.  The  retention  is  due  to  occlu- 
sion of  the  duct,  usually  the  result  of  inflammation.  In 
some  cases  the  duct  remains  pervious,  and  the  retention 
is  due  to  the  altered  character  of  the  secretion  of  the 
gland,  which  becomes  too  viscous  to  pass,  except  under 
unusual  pressure,  along  the  duct. 

These  cysts  contain  clear  yellow  or  chocolate-colored 


44        A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

fluid.  The  diagnosis  of  cyst  of  the  vulvo-vaginal  gland 
is  usually  not  difficult.  If  we  are  in  doubt  in  regard  to 
the  fluid  character  of  the  tumor,  this  may  be  determined 
with  the  exploring-needle. 

Inguinal  hernia,  hydrocele  of  the  canal  of  Nuck,  cysts 
of  the  round  ligament,  and  sacculated  cysts  of  old  her- 
nial sacs  may  be  mistaken  for  cysts  of  the  vulvo-vaginal 
glands.  In  such  cases,  however,  the  tumor  lies  more  in 
the  upper  and  outer  part  of  the  labium  majus,  and  ex- 
tends to,  and  may  be  connected  with,  the  external  in- 
guinal  ring. 

Cysts  of  the  vulvo-vaginal  glands  should  be  treated  by 
free  incision  and  packing,  or  by  extirpation.  If  the  sac 
is  emptied  by  the  aspirator  or  by  a  small  incision,  it  will 
refill.  The  best  method  is  to  extirpate  the  cyst.  In  case 
there  has  been  no  inflammatory  action  binding  the  cyst 
to  surrounding  structures,  extirpation  without  rupture  is 
easy.  If  rupture  occurs,  the  cyst-wall  may  be  dissected 
off  with  the  knife  or  removed  with  the  curved  scissors. 
The  wound  may  be  immediately  closed  with  deep  and 
superficial   sutures. 

Pruritus  Vulvae. — Pruritus  vulvae,  or  itching  of  the 
vulva,  may  be  due  to  a  great  variety  of  causes.  Erup- 
tions of  the  vulva,  such  as  eczema,  cause  itching.  Irri- 
tation from  the  discharge  of  vaginitis,  metritis,  cancer 
of  the  cervix  or  body  of  the  uterus,  the  presence  in  chil- 
dren of  the  thread-worm,  the  irritation  from  diabetic 
urine,  may  result  in  pruritus.  Some  of  the  pathological 
conditions  of  the  uterus,  tubes,  and  ovaries  may  produce 
reflex  irritation  of  the  nerves  of  the  vulva,  and  cause 
itching,  in  a  manner  similar  to  that  in  which  vesical  cal- 
culus causes  itching  of  the  glans  penis. 

The  congestion  of  the  external  genitals  that  accom- 
panies pregnancy  may  also  produce  pruritus. 

There  are  some  cases  of  pruritus  vulvae,  however,  in 
which  no  physical  cause  for  the  intolerable  itching  can 
be  discovered,  and  in  which  minute  examination  of  the 
affected  portions  of  skin  or  mucous  membrane  demon- 


DISEASES  OF  THE  EXTERNAL  GENITALS.      45 

strates  no  pathological  change.  Such  cases  are  called 
idiopathic. 

The  itching  may  be  so  severe  that  the  woman  cannot 
refrain  from  scratching  and  rubbing  the  parts  on  all  oc- 
casions. She  becomes  debarred  from  the  society  of  her 
friends,  and  seeks  relief  in  anodynes  and  hypnotics.  The 
continual  scratching  increases  the  irritation  of  the  vulva, 
and  an  eczematous  eruption  may  result,  which  produces 
an  irritating  discharge  that  spreads  the  irritation  to  other 
parts  of  the  body  with  which  it  may  come  in  contact. 

The  itching  of  pruritus  may  extend  into  the  vagina,  to 
the  skin  of  the  abdomen,  to  the  inner  aspect  of  the  thighs, 
and  to  the  anus. 

In  the  treatment  of  pruritus  it  is  first  of  importance  to 
discover,  if  possible,  the  cause  of  the  itching.  Any 
vaginal  or  uterine  discharge  should  be  investigated. 
Discharge  from  the  uterus  can  be  eliminated  as  a  cause 
by  placing  against  the  external  os  a  pledget  of  cotton, 
frequently  renewed,  to  absorb  the  discharge  before  it 
reaches  the  vulva,  or  the  parts  may  be  kept  clean  by 
frequent  douches.  In  children  the  stools  should  be  ex- 
amined for  the  thread-worm.  The  urine  should  always 
be  examined.  Diabetes  is  a  frequent  cause  of  pruritus 
vulvae  in  old  women.  Any  pathological  condition  of  the 
uterus,  Fallopian  tubes,  and  ovaries  should  be  treated 
before  we  can  eliminate  this  as  a  possible  cause  of  pru- 
ritus. 

In  the  cases  of  so-called  idiopathic  pruritus  in  which 
no  local  lesion  can  be  discovered  attention  should  be 
directed  to  the  general  nutrition  of  the  patient.  As  in 
pruritus  ani,  the  gouty  diathesis  may  cause  the  disease. 
Alcoholic  drinks,  rich  food,  fish  and  shell-fish,  may  assist 
in  its  production. 

Treatment. — A  great  variety  of  local  applications  have 
been  used  for  the  relief  of  pruritus.  In  case  of  diabetes 
the  urine  should,  as  much  as  possible,  be  kept  from  con- 
tact with  the  parts,  which  should  be  thoroughly  dried 
after   urinating,   and   dusted  with    a   powder   consisting 


46        A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

of  equal   parts  of    subnitrate  of  bismuth  and   prepared 
chalk. 

The  following  local  applications  are  useful  in  pruritus: 

Bichloride  of  mercury,  gr.  ^; 

Emulsion  of  bitter  almonds,  §j, 

applied  twice  a  day. 

A  powder  of  i  grain  of  morphine  to  2  grains  of  pre- 
pared chalk,  applied  twice  a  day. 

I^.   Tinct.  opii, 
Tinct.  iodi, 

Tinct,  aconit,  aa.  3v; 

Acid,   carbolic,  .5J, 

applied  once  or  twice  in  the  twenty-four  hours. 

An  ethereal  solution  of  iodoform  sprayed  into  the  folds 
of  the  vulva  with  an  atomizer. 

Cauterization  with  pure  carbolic  acid. 

In  cases  which  have  resisted  all  local  applications  the 
affected  areas  of  mucous  membrane  have  been  excised. 
Even  this  method,  however,  does  not  promise  certain 
cure.  It  should  be  tried,  however,  when  the  pruritus  is 
localized  and  has  resisted  the  milder  forms  of  treat- 
ment. 

Kraurosis  Vulvae. — Kraurosis  vulvae  is  a  very  rare 
disease,  of  chronic  inflammatory  nature,  affecting  the 
vulva.  The  disease  is  characterized  by  cutaneous 
atrophy,  with  very  marked  shrinking  and  contraction  of 
the  vaginal  orifice.  The  lesions  may  be  unilateral  or 
circumscribed,  but  usually  the  tissues  of  the  labia  majora, 
the  nymphae,  and  the  area  surrounding  the  clitoris  and 
urinary  meatus  are  more  or  less  involved.  The  cause  of 
the  disease  has  not  as  yet  been  determined.  It  has  been 
observed  at  every  age  after  puberty,  in  the  nulliparae  as 
well  as  the  multiparae,  and  in  the  parturient  woman.  It 
must  be  differentiated   from  pruritus   and  the  atrophic 


DISEASES  OF  THE  EXTERNAL  GENITALS.     47 

changes  which  take  place  after  the  physiological  and 
induced  meuopa:use. 

The  first  symptoms  noticed  by  the  patient  are  usually 
those  of  pruritus— an  intense  itching  and  burning  about 
the  vulva.  In  some  cases  the  affected  tissue  early 
becomes  excessively  hyperplastic.  The  mucous  mem- 
brane and  the  skin  of  the  vulva  are  often  discolored, 
small  red  spots  appearing,  which  are  sensitive  to  touch. 
Later  a  peculiar  shrinking  of  the  superficial  tissue  takes 
place,  and  the  diseased  surfaces  become  dry  and  whit- 
ened. The  nymphae  gradually  disappear,  fusing  with 
the  labia  majora ;  and  the  mucous  membrane  and  skin 
become  shiny  and  drawn  smoothly  over  the  shrunken 
clitoris.  Cracks  or  fissures  appear  on  the  dry  surfaces. 
A  sensation  of  drawing  and  shrinking  of  the  vulva  is 
now  usually  experienced.  The  vaginal  orifice  gradually 
narrows  and  contracts,  until  frequently  the  little  finger 
can  scarcely  be  introduced.  When  this  last  condition  of 
atrophy  is  reached,  the  pathological  process  is  arrested, 
the  subjective  sensations  of  shrinking  pass  away,  and  the 
symptoms  resembling  pruritus  are  no  longer  experienced. 
The  shrunken  and  contracted  vaginal  orifice,  however, 
persists  and  is  never  spontaneously  restored. 

Treatment. — Palliative  treatment  by  local  applications 
may  be  tried,  or  a  cure  may  be  attempted  by  operation. 
The  palliative  treatment  is  simply  directed  toward  the 
relief  of  the  subjective  symptoms,  which  at  times  are 
exceedingly  painful.  Pure  carbolic  acid  or  a  solution  of 
cocaine  applied  locally,  or  pure  nitrate  of  silver  applica- 
tions frequently  repeated,  afford  temporary  relief.  Cloths 
wrung  out  of  hot  water  and  placed  over  the  vulva  also 
lessen  the  suffering.  A  solution  of  the  neutral  acetate 
of  lead  in  glycerin,  on  cotton  placed  between  the  labia, 
is  recommended.  Forced  dilatation  of  the  vaginal  orifice 
under  ether  has  been  practised  with  good  result.  The 
most  satisfactory  treatment  is  complete  excision  of  the 
diseased  tissue.  Unless  all  affected  tissue  is  removed, 
the  disease  may  return. 


48        A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Varicose  Tumors  of  the  Vulva. — Varicose  tumors 
of  the  vulva  are  usually  the  result  of  pregnaucy.  They 
may,  however,  accompauy  any  form  of  pelvic  or  abdom- 
inal tumor,  the  pressure  of  which  interferes  with  the  ven- 
ous circulation  of  the  pelvis.  The  varicose  condition 
usually  affects  the  labia  majora.  It  varies  from  a  mere 
increase  in  size  of  the  veins  of  the  vulva  to  a  varicose 
tumor  the  size  of  the  fetal  head.  The  condition,  being 
secondary,  usually  disappears  with  the  removal  of  the 
exciting  cause.  The  labia  may  be  supported  with  a 
compress  and  a  bandage. 

Hematoma  of  the  Vulva. — Hematoma  of  the  vulva 
is  due  to  the  subcutaneous  rupture  of  a  vein.  Blows, 
kicks,  or  falls  cause  this  condition.  It  is  usually  pro- 
duced by  rupture  of  a  varicose  vein  during  pregnancy  or 
labor. 

The  affected  labium  is  purple  in  color  and  may  reach 
the  size  of  a  fetal  head.  When  the  hematoma  is  small 
the  vagina  should  be  kept  as  clean  and  aseptic  as  possi- 
ble, and  a  light  compress  should  be  applied.  Absorption 
usually  takes  place.  If  the  collection  of  blood  is  large 
or  if  it  has  become  infected,  a  free  incision  should  be 
made  into  the  labium,  the  clots  should  be  turned  out,  and 
the  cavity  thoroughly  washed  and  packed  with  gauze. 

Papilloma. — Papillomata  or  warts  of  the  vulva  are  not 
uncommon.  They  may  occur  singly,  scattered  over  the 
vulva  and  the  neighboring  skin,  and  extending  up  the  va- 
gina as  far  as  the  cervix  uteri,  or  they  may  occur  in  large 
cauliflower-like  masses,  forming  tumors  the  size  of  the 
fetal  head.  They  are  pink  or  purplish  in  color.  They 
often  exude  a  bloody,  offensive  discharge,  which  is  capa- 
ble of  exciting  a  similar  condition  by  contact.  Papilloma 
is  usually  the  result  of  gonorrhea  or  syphilis.  It  may, 
however,  be  caused  by  irritation  from  filth  or  by  the 
leucorrhea  of  pregnancy. 

The  treatment  of  papilloma  is  by  excision.  The  small 
warts  should  be  picked  up  with  forceps  and  clipped  off 
with  curved  scissors.     Every  one  should  be  removed  or 


DISEASES  OF  THE  EXTERNAL  GENITALS.     49 

the  condition  may  recnr.  In  the  case  of  large  papil- 
lomatous tumors  the  wound  of  excision  should  be  closed 
with  continuous  sutures.  Pregnancy  is  no  contraindica- 
tion to  excision  of  papillomata. 

The  vulva  may  be  the  seat  of  epithelioma,  lupus,  sar- 
coma, fibroma,  fibromyoma,  myxoma,  lipoma,  or  enchon- 
droma.  These  tumors  present  the  same  characteristics 
and  demand  the  same  surgical  treatment  as  in  other  parts 
of  the  body. 

Small  cysts  have  been  found  in  the  labia  majora  and 
minora,  the  vestibule,  the  hymen,  and  the  clitoris. 

Elephantiasis. — True  elephantiasis  of  the  vulva  (ele- 
phantiasis Arabum)  is  a  rare  disease  in  this  climate.  The 
disease  occurs  especially  in  Barbadoes.  It  may  affect  the 
labia  and  the  clitoris.  The  hypertrophied  labia  may 
attain  the  size  of  the  adult  head. 

The  treatment  of  this  condition  is  excision  of  the 
affected  structures. 

There  is  a  syphilitic  form  of  hypertrophy  or  elephan- 
tiasis of  the  vulva  which  is  not  uncommon  in  this 
country.  The  labia  minora  and  majora  may  be  trans- 
formed into  enormous  flap-like  folds.  Though  at  first 
free  from  ulceration,  this  may  subsequently  result  from 
chafing.  Warty  growths  may  cover  the  hypertrophied 
labia,  the  perineum,  and  the  buttocks.  The  disease 
usually  affects  both  labia,  though  it  may  be  confined 
to  one. 

This  manifestation  of  syphilis  does  not  yield  readily  to 
constitutional  or  local  medicinal  treatment.  Many  cases 
prove  to  be  incurable  by  medicine.  Antisyphilitic  treat- 
ment should  always  be  tried  at  first,  and  if  this  fails,  the 
hypertrophied  structures  should  be  excised  with  the  knife. 

If,  in  such  cases,  there  is  any  doubt  in  regard  to  diag- 
nosis between  syphilis  and  cancer,  a  small  portion  of 
tissue  should  be  excised  and  submitted  to  microscopic 
examination. 

Adhesions  of  the  Clitoris. — Adhesions  between  the 
glans  of  the  clitoris  and  the  prepuce  or  hood  which 
4 


50        A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

covers  it  are  exceedingly  common.  Usually  no  trouble 
whatever  is  caused  by  these  adhesions,  unless  an  accu- 
mulation of  smegma  takes  place,  or  irritation  is  produced 
by  the  presence  of  a  concretion. 

In  case  of  any  irritation  about  the  genitals,  the  prepuce 
and  clitoris  should  always  be  carefully  examined.  In 
fact,  a  careful  examination  of  the  clitoris  should  form  a 
routine  part  of  all  examinations  of  the  external  genitals. 

When  trouble  arises  from  the  presence  of  adhesions, 
the  prepuce  should  be  drawn  back  and  the  adhesions 
freed  with  a  blunt  probe.  A  20  per  cent,  solution  of 
cocaine  should  be  applied  to  the  clitoris  for  ten  minutes 
previous  to  the  operation.  The  wdiole  corona  and  the 
sulcus  back  of  the  corona  should  be  exposed.  The  raw 
surface  should  be  covered  with  vaseline,  and  the  patient 
should  abstain  from  walking  as  long  as  pain  is  caused  by 
it.  The  prepuce  should  be  drawn  back  and  vaseline 
applied  every  day  for  two  weeks,  to  prevent  the  formation 
of  adhesions. 


CHAPTER   IV. 
DISEASES  OF  THE  VAGINA. 

Inflammation  of  the  Vagina. — Acute  inflammation 
of  the  vagina  is  not  a  very  common  affection.  Primary 
inflammation  confined  to  the  vagina  alone  is  unusual. 
The  disease  in  most  cases  is  secondary  to  vulvitis,  ure- 
thritis, or  endo-cervicitis.  The  causes  of  vulvitis  (which 
have  already  been  considered)  are  also  the  causes  of 
vaginitis.  It  is  of  importance  to  remember  that  the  dis- 
ease may  occur  in  children  as  a  result  of  the  same  factors 
which  produce  vulvitis. 

The  exanthemata,  as  measles  and  scarlet  fever,  may 
cause  vaginitis  as  part  of  the  general  involvement  of  the 
skin  and  mucous  membrane  which  occurs  in  these  dis- 
eases.    The  most  usual  cause  is  gonorrhea. 

Several  varieties  of  acute  vaginitis  may  be  recognized — 
the  simple,  the  granular,  the  senile,  and  the  emphysem- 
atous. It  is  unusual  to  find  the  entire  surface  of  the 
vagina  involved.  The  disease  is  confined  to  areas  or 
patches  separated  by  healthy  tissue. 

In  simple  vagmitis  the  inflamed  membrane  remains 
smooth. 

In  granular  vaginitis^  which  is  the  variety  usually  seen, 
the  papillae  are  infiltrated  with  small  cells,  and  are  much 
enlarged,  so  that  the  inflamed  surface  has  a  granular 
appearance. 

Senile  vaginitis  is  due  to  infection  of  portions  of  the 
vaginal  mucous  membrane  that  have  lost  their  epithelium 
as  a  result  of  the  atrophic  changes  of  old  age.  This  dis- 
ease occurs  in  patches  of  various  size,  sometimes  present- 
ing  the    character   of    ecchymosis;    in    other   cases   the 

51 


52         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

patches  have  altogether  lost  the  epithelium,  and  perma- 
nent adhesions  may  take  place  between  areas  which  are 
brought  in  contact.  This  form  of  vaginitis  has  also  been 
called  adhesive  vaginitis.  It  is  said  that  a  similar  con- 
dition may  occur  in  children. 

The  emphysematous  form  of  vaginitis  occurs  in  preg- 
nancy. The  vaginal  walls  are  swollen  and  crepitating. 
The  gas  is  contained  in  the  meshes  of  the  connective 
tissue. 

Acute  vaginitis  is  accompanied  by  dull  pain  and  a 
sense  of  fulness  in  the  pelvis.  The  discomfort  is  in- 
creased by  standing,  walking,  defecation,  and  urination. 
There  is  a  free  discharge  of  serum  or  pus,  which  may  be 
tinged  with  blood.  The  character  of  the  discharge 
depends  upon  the  variety  and  the  period  of  the  disease. 
Inspection,  which  can  best  be  made  through  the  Sims 
speculum,  with  the  woman  in  the  Sims  or  knee-chest 
position,  shows  the  characteristic  lesions  of  inflammation 
of  the  mucous  membrane. 

Acute  vaginitis,  if  neglected,  may  pass  into  the  chronic 
form.  It. usually  lingers  in  the  upper  part  of  the  vagina, 
in  the  fornices,  especially  in  vaginitis  of  gonorrheal 
origin.  By  careful  inspection  we  find  here  one  or  more 
granular  patches  of  inflammation,  which  cause  a  vaginal 
discharge  from  which  man  may  be  infected,  and  from 
which  infection  of  the  upper  portion  of  the  genital  tract, 
the  uterus,  and  the  Fallopian  tubes  may  be  derived. 

Treatment. — Vaginitis,  especially  of  the  gonorrheal 
form,  should  be  treated  vigorously,  and  treatment  should 
be  continued  until  all  traces  of  inflammation  have  dis- 
appeared. Inflammation  of  any  part  of  the  lower  portion 
of  the  genital  tract  may  have  the  most  disastrous  conse- 
quences if  it  extends  to  the  uterus  and  the  Fallopian 
tubes. 

The  woman  should  be  kept  as  quiet  as  possible.  The 
bowels  should  be  moved  freely  with  saline  purgatives. 
She  should  take,  three  times  in  twenty-four  hours,  lying 
upon  her  back,  a  vaginal  douche  of  one  gallon  of  a  bo- 


DISEASES  OF  THE   VAGINA.  53 

racic-acid  solution  (sj  to  the  pint).     The  temperature  of 
the  solution  should  be  about  110°  F. 

If  the  disease  be  of  gonorrheal  origin,  a  warm  bichloride 
solution  (i  :  5000)  should  be  used  in  the  same  way. 

After  the  acute  symptoms  have  subsided  local  applica- 
tions should  be  made,  in  addition  to  the  douches.  The 
woman  should  be  placed  in  the  knee-chest  position,  and 
the  vagina  should  be  thoroughly  exposed  with  the  Sims 
speculum.  If  necessary,  the  vaginal  surface  should  be 
gently  cleaned  with  warm  water  and  cotton.  A  4  per 
cent,  solution  of  cocaine  may  be  applied  to  the  vagina  if 
there  is  much  pain.  Then  the  entire  vaginal  surface 
should  be  painted  with  a  solution  of  bichloride  of  mer- 
cury (i  :  1000).  These  applications  should  be  made 
daily  until  the  disease  is  cured.  The  vaginal  douches 
should  be  continued  at  the  same  time. 

In  the  chronic  form  of  the  disease  and  in  senile  vagi- 
nitis the  local  patches  of  inflammation  should  be  painted 
once  a  day  with  a  solution  of  nitrate  of  silver,  5  to  10 
per  cent.,  or  stronger  if  the  condition  does  not  yield. 
The  senile  form  of  vaginitis,  being  dependent  upon  a 
general  condition,  is  often  impossible  to  cure.  We  can 
sometimes  relieve  the  discomfort  by  applying  boracic- 
acid  ointment  (3J  to  ij)  to  the  vagina.  The  application 
.of  pure  carbolic  acid  to  the  inflamed  patches  sometimes 
does  good. 

Urethritis  usually  accompanies  a  gonorrheal  vaginitis, 
and  demands  coincident  treatment. 

Tumors  of  the  Vagina. —  Vaginal  Cysts. — Well-de- 
fined cysts  are  sometimes  found  in  the  vaginal  walls. 
They  occur  at  all  ages  from  childhood  to  old  age. 

Vaginal  cysts  are  usually  single.  They  vary  in  size 
from  that  of  a  pea  to  that  of  a  fetal  head.  The  vaginal 
mucous  membrane  covers  the  free  surface  of  the  cyst, 
and  may  either  be  movable  over  it  or  may  be  much  at- 
tenuated and  closely  incorporated  with  the  cyst-wall. 
Vaginal  cysts  may  be  sessile  or  more  or  less  pedunculated. 
The  internal  surface  of  the  cyst  is  usually  covered  with 


54        A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

cylindrical  epithelium,  which  is  sometimes  ciliated.  The 
contents  vary  in  consistency  and  color.  They  are  often 
viscid,  transparent,  and  of  a  pale  yellow  tint.  They  may 
contain  pus  or  altered  blood. 

The  origin  of  vaginal  cysts  has  been  much  disputed. 
It  is  probable  that  they  arise  from  the  remains  of  the 
Wolffian  canal — the  canal  of  Gartner.  In  the  embryo 
the  transverse  or  longitudinal  tubule  of  the  parovarium 
extends  to  the  side  of  the  uterus  and  thence  down  the 
side  of  the  vagina  to  the  urethral  orifice.  It  persists  in 
this  condition  in  some  of  the  lower  animals — the  sow  and 
the  cow — and  may  also  persist  as  a  closed  tube  in  woman. 
In  such  cases  it  may  become  distended  and  form  the 
vaginal  cyst. 

The  treatment  of  vaginal  cyst  is  removal.  If  the  tu- 
mor be  situated  near  the  vulva,  it  may  be  extirpated  by 
careful  dissection.  If  this  operation  be  deemed  imprac- 
ticable, partial  excision  of  the  cyst  should  be  practised. 
The  tumor  should  be  seized  with  a  tenaculum,  opened  by 
the  scissors,  and  part  of  the  wall,  with  the  overlying 
mucous  membrane,  should  be  excised.  The  interior  of 
the  cyst  should  then  be  packed  with  gauze. 

Fibroid  Tumors  of  the  Vagina. — Fibroid  tumors  some- 
times occur  in  the  vagina.  They  are  usually  found  in 
the  upper  part  of  the  anterior  wall.  They  are  sometimes 
adherent  to  the  urethra.  They  are  usually  of  small  size, 
but  may  attain  a  diameter  of  six  inches.  The  treatment 
of  such  tumors  is  removal. 

Cancer  and  sarcoma  may  attack  the  vagina,  though 
these  diseases  as  primary  conditions  are  very  rare.  When 
possible,  complete  removal  should  be  done. 


CHAPTER  V. 
ANATOMY  AND  MECHANISM  OF  THE  PERINEUM. 

An  accurate  knowledge  of  the  anatomy  and  mechanism 
of  the  female  perineum  is  essential  to  an  understanding 
of  the  nature  and  treatment  of  injuries  to  this  structure. 
The  anatomical  structures  lying  between  the  anus  behind 


Dorsal  vein  of  clit- 
oris. 

Dorsal  artery  of  clit- 
oris. 

Inferior  pudendal 
nerve. 

Artery  of  bulb. 


a~  Ptidic  nerve. 


Inter7ial  ptidic 

artery. 
Inferior  hemor- 

7  hoidal  artery. 
Inferior  heinor- 

rhoidal  nerve. 

Tendinous  perineal 

center. 
Superficial  trans- 

versus  perincei 

viuscle. 


Fig.  19. — Dissection  of  female  perineum  :  on  the  left  side  the  perineal  mus- 
cles are  exposed  by  the  reflection  of  the  perineal  fascia;  on  the  right  side  the 
muscles  and  the  superficial  layer  of  the  triangular  ligament  have  been  removed, 
thereby  exposing  the  deep  layer  of  the  Hgament.    S.  V,  Sphincter  vaginae  muscle, 

and  the  symphysis  pubis  in  front  are  those  that  most 
directly   interest    the    gynecologist.       Proceeding    from 

55 


56 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


below  upward,  we  find  tlie  following  structures  l^-'ing  in 
superimposed  planes:  the  skin,  the  superficial  fascia,  the 
deep  layer  of  the  superficial  fascia,  the  transversus  perinaei 
and  the  sphincter  vaginae  muscles,  the  anterior  layer  of 
the  triangular  ligament,  the  posterior  layer  of  the  trian- 
gular ligament,  the  levator  ani  muscle  (Fig.  19). 

The  vagina  passes  through  these  structures.  They 
surround  and  support  the  ostium  vaginae  as  the  fascia 
and  muscles  surround  and  support  the  opening  of  the 


Fig.  20. — Dissection  of  female  perineum,  showing  the  deeper  structures  after 
removal  of  the  levator  and  sphincter  ani  muscles. 

rectum  or  the  anus.  The  muscles  and  fasciae  are 
attached  in  the  median  line  between  the  anus  and  the 
vagina,  and  therefore  this  part  of  the  body,  which  is 
called  the  perineum,  is  supported  or  maintained  in  its 
proper  position  by  these  various  structures.  The  trans- 
versus  perinaei  arises  from  the  ramus  of  the  ischium  and 


ANATOMY  OF  THE  PERINEUM. 


57 


is  inserted  in  the  perineum.  The  bulbo-cavernosus,  or 
sphincter  vaginae,  arises  in  the  perineum  and  is  inserted 
in  and  about  the  clitoris.  The  inner  fibers  of  the  levator 
ani  arise  from  the  symphysis  pubis  and  are  inserted  in 
the  perineum  and  the  lower  part  of  the  vagina  (Fig.  20). 
When  these  muscles  contract,  their  action,  therefore,  is 
to  draw  the  perineum  upward  and  forward.  At  the  same 
time  the  anus  is  drawn  upward  and  forward,  and  so  also 
is  the  posterior  margin  of  the  ostium  vaginae  and  the 
lower  portion  of  the  posterior  vaginal  wall. 


Fig.  21. — Muscular  floor  of  the  pelvis  seen  from  above. 


The  vagina  has  no  circular  sphincter  like  the  anus,  but 
the  vaginal  mouth  is  kept  closed  by  the  action  of  the 
transversus  perinsei,  sphincter  vaginae,  and  levator  ani 
muscles,  which  draw  the  perineum  forward,  and  thus 
keep  the  posterior  vaginal  wall  in  apposition  with  the 
anterior  wall. 

This  sling  of  muscles  and  fascia,  which  surrounds  and 
supports  the  opening  of  the  vagina,  may  readily  be  felt  in 


58 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


the  nulHparous  woman  by  introducing  the  finger  in  the 
vagina  and  pressing  backward  and  outward  toward  the 
ischio-rectal  fossa.  We  then  feel  plainly,  immediately 
within  the  ostium  vaginae,  a  firm  resisting  band  of  tissue, 
apparently  about  half  an  inch  broad,  embracing  the  pos- 
terior portion  of  the  lower  vagina.  This  band  is  formed 
by  the  inner  edges  of  the  various  muscles  and  planes  of 
fascia  that  have  been  described. 

The  vagina  extends,  as  a  transverse  slit  in  the  pelvic 


Fig.  22. — Sagittal  section  showing  relations  of  the  several  layer.s  of  fascia  within 
the  pelvic  floor  (Dickinson). 


floor,  upward  and  backward,  approximately  in  the  direc- 
tion of  a  line  drawn  from  the  ostium  vaginae  to  the 
fifth  sacral  vertebra.  It  is  approximately  parallel  with 
the  conjugate  of  the  brim,  so  that  when  the  woman  is 
erect  the  long  axis  of  the  vagina  is  inclined  at  an  angle 


ANATOMY  OF  THE  PERINEUM. 


59 


of  60°  to  the  horizon.  The  vagina  is  not  a  vertical  open 
tube:  it  is  a  slit  in  the  pelvic  floor,  in  health  always 
closed  by  the  accurate  apposition  of  the  anterior  and  pos- 
terior walls  (Fig.  21).  The  anterior  vaginal  wall  is  about 
2^  inches  long  in  a  vertical  mesial  line.  The  posterior 
vaginal  wall  is  about  3  ^  inches  long.     The  vaginal  walls 


Fig. 


23. — Section   illustrating    the    characteristic    form   of   the    vaginal   cleft 
(Henle) :   Ua,  urethra ;    Va,  vagina ;  Z,  levator  ani ;  R,  rectum. 


are  triangular  in  shape,  being  broader  above  than  below. 
The  shape  of  the  normal  vagina  at  the  pelvic  outlet  is 
shown  by  Fig.  23.  The  section  here  shows  the  vaginal 
slit  of  the  shape  of  the  letter  H.  The  portions  of  the 
slit  extending  backward  and  somewhat  outward  are  called 
the  vaginal  sulci  or  furrows.  They  are  directions  of 
diminished  resistance  in  which  tears  are  liable  to  occur. 


CHAPTER   VI. 
INJURIES  TO  THE  PERINEUM. 

The  injuries  to  the  perineum  that  may  result  from 
childbirth  are  classified  according  to  the  position  or  the 
direction  and  extent  of  the  laceration.  They  are  as 
follows:  slight  median  tear;  median  tear  involving  the 
sphincter  ani;  tear  in  one  or  both  of  the  vaginal  sulci; 
subcutaneous  laceration  of  the  muscles  and  fascia. 

All  these  injuries  demand  operative  treatment.  The 
operation  for.  the  repair  of  injuries  to  the  perineum  is 
called  perineorrhaphy.  It  is  called  immediate  or  pri- 
mary, intermediate,  and  secondary  perineorrhaphy,  ac- 
cording to  the  time  after  the  receipt  of  the  injury  at 
which  the  operation  is  performed.  The  primary  operation 
is  done  during  the  first  twenty-four  hours.  The  primary 
operation  should  always  be  performed.  A  careful  inspec- 
tion of  the  perineum  and  the  posterior  vaginal  wall  should 
always  be  made  after  labor,  and  any  laceration  should 
be  repaired  within  twenty-four  hours.  The  advantages 
of  the  primary  operation  are  many.  The  parts  are 
usually  so  numb  that  it  is  i*iot  necessary  to  administer  an 
anesthetic.  No  denudation  is  necessary,  and  therefore 
no  tissue  need  be  sacrificed.  The  woman  is  spared  the 
pain  and  discomfort  of  granulation  and  cicatrization. 

The  bad  results  that  follow  neglect  of  the  primary 
operation  are  very  numerous,  and  will  be  studied  here- 
after. The  injured  muscles  retract,  and,  being  function- 
ally useless,  undergo  atrophy,  and  when  finally  repaired 
never  possess  their  former  strength.  Involution  in  the 
vagina  and  the  uterus  may  be  arrested,  and  all  the  disas- 
ters incident  to  subinvolution  may  appear.  Vaginal 
and  uterine  prolapse  occur;  the  natural  supports  of  the 

60 


INJURIES  TO  THE  PERINEUM.  6l 

vagina  and  uterus  become  stretched,  and,  though  after- 
ward the  perineum  may  be  restored,  yet  it  may  be  found 
impossible  to  retain  the  uterus  in  its  proper  position.  It 
is  always  good  surgery  to  repair  an  injury  as  soon  as 
possible. 

When  practicable,  a  certain  amount  of  preparation  of 
the  patient  should  be  made  before  the  operation  of  per- 
ineorrhaphy. This  is  most  easily  effected  before  the 
intermediate  and  secondary  operations.  The  vagina 
and  the  vulva  should  be  sterilized,  and  the  intestinal 
tract  should  be  emptied.  Thorough  evacuation  of  the 
bowels  is  most  important  when  the  sphincter  ani  has 
been  injured,  because  it  is  desirable,  after  operation 
for  this  lesion,  that  the  bowels  should  not  be  moved  for 
five  or  six  days.  A  saline  purgative  should  be  admin- 
istered on  an  empty  stomach  about  five  hours  before  the 
operation,  and  a  rectal  injection  of  soap  and  water 
should  be  administered  about  one  hour  before  the  ope- 
ration. Whatever  purgative  be  employed,  it  should  be 
administered  at  such  a  time  that  its  action  shall  have 
ceased  by  the  time  of  the  operation.  If  this  precau- 
tion is  not  observed,  there  may  be  a  discharge  of  feces 
that  will  infect  the  wound  and  interfere  with  the  man- 
ipulations. 

For  operation  upon  the  perineum  the  woman  should 
be  placed  in  the  dorso-sacral  position  (Fig.   i,  page  25). 

The  intermediate  operation  is  performed  during  the 
granulation  period — ten  days  or  two  weeks  after  labor. 
At  this  time  the  raw  surfaces  are  covered  with  granula- 
tion-tissue and  bathed  with  pus.  The  edges  of  the  wound 
and  the  surrounding  tissue  may  be  hard  and  swollen 
from  infiltration  with  inflammatory  products.  In  the  in- 
termediate operation  it  is  necessary  to  administer  an  anes- 
thetic or  to  anesthetize  the  parts  locally  with  a  10  per 
cent,  solution  of  cocaine. 

All  cicatricial  tissue,  granulation-tissue,  and  rough 
edges  should  be  scraped  away  with  the  knife,  the  scis- 
sors,  or  the  curet.      The  raw  surfaces  should  be  thor- 


O," 


A   /EXr-BOOA'  OF  D/S£.-iS£S  OF  U'OMFX. 


oughly  washed  with  a  50  per  cent,  solution  of  j'leroxide 
of  hydrogen  and  a  i  :  1000  sohition  of  bichloride  of  mer- 
cury.    The  sutures  should  then  be  introduced. 

The  secondan-  ojv?ration  is  performed  at  any  time  after 
cicatrization  luis  occurrevl — c^ften  many  years  after  the 
receipt  of  the  injnr>\  This  operation  is  at  present  one 
of  the  cvMumonest  in  gynecology,  because  the  injury  is 
not  detectet.1.  is  neglected,  or  is  improperly  repaired  after 
labor.    In  the  secoudar>-  operation  an  anesthetic  is  neces- 


-  U 


Fig.  24. — Emmei's  ivrine-il  scissors, 

sar>\  The  mucous  membnine  must  be  removed  or  de- 
nuded on  the  posterior  wall  and  about  the  mouth  of  tlie 
Vvigina,  in  order  that  the  lacerated  stnictures  may  be 
brought  ag-ain    in   apposition.     The   denudation    is   best 


Fig.  25. — Cuired  scissors  for  denuding. 

made  by  means  of  scissors  curved  on  tlie  flat  ^^Figs.  24 
and  25I 


Fig.  ^. — Tenacula  for  plasdc  operations. 

The  Strip  of  mucous  membrane  to  be  removed  is  picked 
up  with  a  tenaculum  (^Fig.    26)  or  with  tissue  forceps 


INJURIES  TO  THE  PERINEUM. 


^2. 


(Fig.  27);  the  scissors  are  placed  with  the  blades  parallel 
to  the  surface  to  be  denuded,  and  the  strip  is  cut  away 


Fig.  27. — Tissue-forceps. 

evenly,  in  one  piece  if  possible.     A  similar  contiguous 
strip  is  removed,  and  so  on  until  the  necessary-  surface  is 


Fig.  28. — Sponge-holder, 


bare, 
gation 
For 
needles 


Fig.  29.— 
perineal 


Sponges  in  holders  (Fig.   28)  or  continuous  irri- 

may  be  used  to  remove  blood. 

all   operations    on    the    perineum    round-pointed 

cur^'ed  at  the  tip  should  be  used  (Fig.  29).  The 
tissues  are  always  sufficiently  soft  for  the 
passage  of  such  a  needle.  A  needle  with 
a  cutting  edge  is  unnecessary  and  may 
increase  the  bleeding. 

The  needle  may  be  held  in  any  kind 
of  needle-holder  preferred.  The  Emmet 
needle-holder  (Fig.  30) "  is  very  conve- 
nient. 

The  point  of  the  needle  should  be 
guided  and  held  by  the  tenaculum.  The 
tenaculum  must  always  be  held  in  a 
plane    parallel   with    the    plane   of   the 


■Emmet's 
needle. 


Fig.  ;o. — Emmet's  needle-holder. 


needle-holder ;    otherwise   the   needle-point   may    escape 
from  the  embrace  of  the  tenaculum. 


64         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Silver  wire  and  silkworm  gut  are  the  best  sutures  in 
the  operation  of  perineorrhaphy. 

The  suture  is  conveniently  attached  to  the  needle  by 
means  of  a  silk  carrier  (Fig.  31). 


Perineal  needle  with  silk  carrier. 


The  sutures  may  be  fastened  by  passing  the  ends 
through  a  perforated  shot  which  is  slipped  down  to  the 
line  of  union  and  compressed  by  the  shot-compressor 
(Fig.  32).     x\ll  blood  should  be  carefully  removed  from 


Fig.  32. — Shot-compressor. 


the  surfaces  that  are  brought  together.  The  sutures 
should  only  be  sufficiently  tense  to  produce  accurate  ap- 
position. A  light  gauze  drain  should  be  introduced  in 
the  vagina,  and  should  be  removed  in  forty-eight  hours. 
Afterward  one  vaginal  douche  of  about  a  quart  of  warm 
bichloride  solution  (i  :  2000)  should  be  administered  every 
day.  After  the  douche  the  labia  should  be  separated  and 
the  vagina  carefully  dried  by  cotton  held  in  dressing-for- 
ceps. Except  in  those  cases  in  which  the  sphincter  ani 
is  involved,  the  bowels  may  be  moved  on  the  second  or 
third  day.  The  woman  should  stay  in  bed  for  two  weeks, 
at  the  end  of  which  time  the  sutures  should  be  removed. 


INJURIES  TO  THE  PERINEUM. 


65 


She  should  avoid  heavy  lifting,  long  standing,  and  bi- 
cycle- or  horseback-riding  for  two  months  after  the  ope- 
ration. Constipation  should  always  be  avoided.  Coitus 
may  be  resumed  six  weeks  after  operation. 

The  special  forms  of  operation  will  be  discussed  in  the 
consideration  of  the  varieties  of  perineal  injury. 

Slight  Median  I/aceration  of  the  Perineum. — In 
this  injury  the  tear  takes  place  through  the  fourchette. 
Posteriorly  it  may  extend 
as  far  as  the  sphincter  ani 
muscle.  Upward  it  may 
extend  for  an  inch  up  the 
posterior  vaginal  wall.  The 
appearance  of  this  tear  is 
shown  in  Fig.  33.  It  will 
be  noted  that,  as  this  tear 
takes  place  in  the  median 
line,  none  of  the  muscles 
that  support  the  perineum 
are  involved,  nor  are  the 
planes  of  fascia  injured. 
The  perineum  is  slightly 
split,  and  the  insertions  and 
origins  of  the  muscles  and 
the  fascia  are  slightly  sep- 
arated. The  supporting 
structures  of  the  perineum 
and  the  pelvic  floor  are, 
however,  uninjured. 

If  this  tear  is  detected 
after  labor,  it  should  be  closed  by  the  immediate  opera- 
tion. A  slight  tear  involving  chiefly  the  cutaneous 
aspect  of  the  perineum  should  be  closed  by  three  or  four 
sutures  introduced  from  the  outside,  as  in  Fig.  33.  The 
needle  should  be  introduced  about  a  quarter  of  an  inch 
from  the  edge  of  the  wound.  It  should  not  be  passed 
parallel    with    the   plane   of   the   lacerated   surface,   but 

should  be  .swept  outward  and  then  inward  toward  the- 
5 


Fig.  33. — Recent  slight  median 
laceration  of  the  perineum :  sutures 
iutroduced. 


66 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


angle  at  the  bottom  of  the  tear  (Fig.  34).     It  may  either 
emerge  at  the  angle  and  be  re-introduced,  or  it  may  be 


Correct. 


,..'  Incorrect. 


Fig.  34. — Diagram  representing  the  correct  and  the  incorrect  method  of  passing 
the  suture  for  closure  of  slight  perineal  laceration. 

passed  directly  through  to  the  skin-margin  on  the  oppo- 
site side  of  the  wound.  If 
the  suture  is  passed  in  this 
way,  there  will  be  perfect  ap- 
position throughout  the  whole 
surface  of  laceration.  If  the 
sutures  are  improperly  passed, 
there  may  result  only  apposi- 
tion of  the  skin-edges. 

If  the  laceration  extends 
up  the  posterior  vaginal  wall, 
two  sets  of  sutures  must  be 
introduced — one  on  the  vag- 
inal aspect  of  the  tear,  and 
one  on  the  skin  aspect  (Fig. 

35)- 

The    secondary    operation 

of  perineorrhaphy  is  not  in- 
dicated in  slight  median 
lacerations  of  the  perineum 
that  may  have  been  neglected 
at  the  time  of  labor,  as  the 
integrity  of  the  pelvic  floor 
is  practically  unaffected  by 
them. 
Median  Tear  involving  the  Sphincter  Ani. — In  this 


Fig.  35. — Recent  slight  median 
laceration  of  the  perineum  extend- 
ing up  the  posterior  vaginal  wall : 
sutures  introduced  on  the  vaginal 
and  cutaneous  aspects. 


INJURIES  TO  THE  PERINEUM.  67 

form  of  injury  the  laceration  takes  place  in  the  median 
line  and  extends  backward  through  the  sphincter  ani 
muscle,  and  perhaps  upward  for  one  or  more  inches 
through  the  recto-vaginal  septum.  Permanent  inconti- 
nence of  feces  results. 

Though  this  is  a  most  extensive  injury  attended  by 
most  unpleasant  results,  yet  it  will  be  seen  that  none  of 
the  supporting  structures  (the  fascia  and  the  muscles)  that 
support  the  pelvic  floor  are  injured  by  it. 

The  perineum  is  split  in  the  middle,  but  the  muscles 
attached  to  it,  being  uninjured,  are  still  able  to  draw  the 
two  halves  of  the  perineum  forward,  thus  supporting  the 
posterior  vaginal  wall  and  keeping  the  vagina  closed. 
There  is  but  very  little  tendency  to  separation  of  the  two 
parts  of  the  split  perineum  by  lateral  traction,  the  only 
muscle  that  acts  at  all  in  this  direction  being  the  feeble 
transverse  perineal  muscle. 

Therefore,  though  there  is  loss  of  power  of  the  sphinc- 
ter ani  muscle,  yet  in  this  injury  the  woman  may  not 
suffer  any  of  the  consequences  of  loss  of  power  in  the 
support  of  the  pelvic  floor,  such  as  vaginal  and  uterine 
prolapse. 

After  laceration  of  the  perineum  through  the  sphincter 
ani  the  divided  muscle  retracts  so  that  it  embraces  only 
the  posterior  margin  of  the  anus.  If  the  injury  be  not 
repaired  immediately,  retraction  and  atrophy  progress,  so 
that  in  time  the  sphincter  muscle,  lying  posterior  to  the 
anal  opening,  may  be  but  half  an  inch  in  length  and  of 
very  much  less  than  its  normal  thickness.  Cicatrization 
takes  place,  and  the  parts  present  the  appearance  shown 
in  Fig.  37. 

Notwithstanding  the  atrophy  and  retraction  of  the 
muscle,  continence  may  be  re-established  by  operation, 
though  many  years  may  have  elapsed  since  the  receipt  of 
the  injury. 

Notwithstanding  the  very  obvious  reasons  for  the  per- 
formance of  the  immediate  operation  for  the  relief  of 
this  condition,    it  is  yet  very  often   neglected,   and  the 


68 


A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


gynecologist  is  called  upon  to  repair  the  injury  many 
years  after  its  occurrence. 

The  important  part  of  the  operation  for  this  injury 
consists  in  the  repair  of  the  muscle.     In  many  operations 

the  recto-vaginal  septum 
is  repaired  and  the  cutane- 
ous portion  of  the  peri- 
neum is  repaired,  but  the 
operator  fails  to  secure  in 
his  sutures  the  sphincter 
ani  muscle,  and  conse- 
quently the  incontinence 
is  not  cured  (see  Fig.  36). 
The  mistake  often  made  is 
that  the  sutures  that  are 
introduced  to  close  the  an- 
terior margin  of  the  anus 
are  inserted  too  far  forward 
and  too  far  out  to  catch 
the  ends  of  the  sphincter 
ani  muscle,  which  has  re- 
tracted so  that,  in  some 
cases,  it  lies  altogether  be- 
hind the  anal  opening. 
Or,  perhaps,  only  the  outer  fibers  of  the  sphincter  ani  are 
included  in  the  suture,  and  partial  incontinence  results. 
The  position  of  the  sphincter  ani  muscle  is  indicated 
by  the  corrugated  or  wrinkled  skin  overlying  it.  The 
ends  of  the  muscles,  being  retracted,  do  not  lie  in  the 
plane  of  the  laceration,  but  their  position  is  marked  by 
a  depression  or  dimple  (Fig.  37). 

The  technique  of  the  primary  operation  is  included  in 
a  consideration  of  that  of  the  secondary  operation,  the 
only  difference  being  that  in  the  latter  operation  denuda- 
tion is  necessary. 

The  parts  should  first  be  denuded,  so  that  they  present 
the  same  raw  surface  that  was  exposed  in  the  original 
laceration. 


Fig.  36. — Imperfect  repair  of  the 
sphincter  ani.  The  muscle  has  not 
been  included  by  the  sutures,  and  does 
not  surround  the  anal  opening. 


INJURIES  TO  THE  PERINEUM. 


69 


The  lower  end  of  the  recto-vaginal  septum  that  forms 
the  anterior  margin  of  the  anal  opening  is  usually  thin 
and  cicatricial  where  the  mucous  membranes  of  the 
vagina  and  rectum  unite.  All  this  cicatricial  tissue 
should  be  cut  away,  and  the  mucous  membrane  of  the 
vagina  may  be  drawn  forward  and  separated  by  dissection 
from  the  mucous  membrane  of  the  rectum,  in  order  to 
make  a  somewhat  broader  surface  through  which  to  pass 
the  sutures. 

Special  care  should  be  directed  to  the  denudation  of 
the  ends  of  the  sphincter  muscle.  The  tissue  lying  at 
the  bottom  of  the  depression  that  marks  the  end  of  the 
sphincter  should  be  picked  up  with  forceps  or  a  tenaculum 
and  carefully  cut  away.  In  removing  tissue  attached  to 
the  mucous  membrane 
of  the  rectum  the  opera- 
tor should  avoid  cutting 
the  healthy  portion  of 
this  mucous  membrane, 
as  bleeding  from  it  is 
often  annoying. 

The  first  suture  should 
be  introduced  at  the  mar- 
gin of  the  anal  opening, 
within  the  area  of  corru- 
gated skin  that  marks  the 
position  of  the  muscle, 
and  behind  the  depres- 
sion that  marks  the  end 
of  the  muscle.  The  end 
of  the  muscle  may  be 
seized  with  a  tenaculum 
or  with  tissue-forceps  and 
drawn  out  to  ensure  that 
the  suture  includes  mus- 
cular tissue.  The  needle 
is  then  passed  near  the  edge  of  the  rectal  mucous  mem- 
brane to  the  apex  of  the  tear  in  the  recto-vaginal  septum, 


Fig.  37. — An  uUl  laceration  through 
the  sphincter  ani.  The  sphincter  muscle 
lies  behind  the  anal  opening.  Its  position 
is  indicated  by  the  wrinkled  skin ;  its  ends 
are  marked  by  the  depressions  on  each 
side  of  the  anal  opening. 


70 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


whence  it  emerges.  It  is  re-iutroduced  here,  and  passed 
in  a  similar  manner  to  emerge  upon  the  opposite  side, 
behind  the  other  end  of  the  sphincter  ani  muscle  (Fig. 
38).  This  suture  is  introduced  very  near  the  edge  of 
the  wound,  so  that  there  may  not  be  any  inversion  of 
skin  to  prevent  perfect  apposition  of  the  ends  of  the 
muscle.  In  case  there  has  been  much  retraction  of 
the  sphincter  ani  muscle,  the  ends  of  the  suture  may 
appear  to    lie  behind  the   anal  opening.       The   second 


Fig.   38. — Denudation   and    su-  Fig.  39. — Completed  operation.     The 

litres  for  repair  of  laceration.      The  anal  opening  is  surrounded  by  the  sphinc- 

two  posterior  sutures  pass  through  ter.      One    shot   has  disappeared   in  the 

the  sphincter  muscle.  anus.     The  anterior  suture  is  omitted. 


suture  is  introduced  somewhat  outside  of  the  first — still, 
however,  within  the  area  of  the  sphincter  muscle — and 
is  passed  in  a  similar  manner  to  emerge  in  the  apex  of 
the  recto-vaginal  tear  anterior  to  the  first  suture.  The 
remaining  sutures  to  close  the  perineum  are  passed  as 
already  described  in  the  operation  for  slight  median  tear 
of  the  perineum.     When  the  sutures  are  shotted,  great 


INJURIES  TO  THE  PERINEUM. 


71 


care  must  be  exercised  in  making  perfect  apposition  of 
the  parts  brought  together  by  the  first  two  sutures. 
Sometimes  such  apposition  is  more  easily  secured  by 
shotting  the  anterior  perineal  sutures  first.  When  the 
operation  is  completed  the  first  suture  through  the 
sphincter  is  sometimes  drawn  upward,  so  that  it  disap- 
pears in  the  anal  opening.  If  the  muscle  has  been  prop- 
erly secured,  it  will  be  observed  that  the  anal  opening 
is  surrounded  by  the  ring  of  wrinkled  or  corrugated  skin 

(I^ig-  39)- 

After  this  operation  the  bowels  should  not  be  moved 

for  five  or  six  days.  The  intestinal  contents  should 
then  be  rendered  as  soft  as  possible  by  the  administra- 
tion of  small  repeated  doses  of  some  saline  purgative, 
as  Rochelle  salts  3J,  every  hour  for  five  or  six  hours. 
If  the  woman  feels  that  she  may  have  difficulty  in 
having  a  passage,  a  rectal  injection  of  a  pint  of  soapsuds 
and  warm  water  should  be 
very  carefully  adminis- 
tered. The  nozzle  of  the 
syringe  should  be  well 
greased  and  passed  along 
the  posterior  margin  of 
the  anal  opening.  After 
this  the  bowels  should  be 
moved  every  forty-eight 
hours.  The  sutures  should 
be  removed  at  the  end  of 
two  weeks.  , 

I/aceration  through 
the  Sphincter  Ani,  in- 
volving the  Recto-vag- 
inal Septum. — In  case 
the  recto-vaginal  septum 
has  been  torn,  it  may  be 
necessary  to  repair  the 
tear  before  operating  on 
the  perineum  and  the  sphincter  ani  muscle 


Fig.  40.  —  Laceration  through  the 
sphincter  ani,  extending  up  the  recto- 
vaginal septum. 


In  some 


72 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


cases  the  laceration  extends  for  three  or  more  inches  up 
the  septum  (Fig.  40). 

The  edges  of  the  septal  tear  should  be  denuded,  the 
strip  of  tissue  being  cut  away  to  the  line  of  normal  rectal 
mucous  membrane.  Annoying  bleeding  may  occur  if  the 
mucous  membrane  of  the  rectum  is  injured.  The  denu- 
dation may  be  extended  on  the  vaginal  aspect  as  far  as  is 
necessary  to  obtain  a  sufficiently  broad  surface  for  approxi- 
mation. 

The  tear  in  the  septum  should  be  closed  by  interrupted 
sutures  introduced  from  the  vaginal  aspect.     The  suture 


Fig.  41. — Denudation.     Sutures  FiG.  42. — Laceration  of  the  recto-vagi- 

introduced  to  close  the  laceration     nal  septum  closed.     The  operation  is  com- 
of  the  recto-vaginal  septum.  plated  by  the  introduction  of  sutures  as  in 

Fig-  38. 

is  passed  through  the  vaginal  mucous  membrane  at  about 
an  eighth  of  an  inch  from  the  edge  of  the  wound,  and 
emerges  in  the  edge  of  the  rectal  mucous  membrane.  It 
should  not  pass  through  the  rectal  mucous  membrane. 
After  the  sutures  in  the  recto-vaginal  septum  have  been 
shotted,  the  operator  may  proceed  to  repair  the  perineum 
and  the  sphincter  ani  muscle  (Figs.  41,  42). 


INJURIES  TO  THE  PERINEUM.  73 

There  is  a  variety  of  perineal  laceration  (between  the 
first  slight  median  laceration  and  the  second  complete 
laceration  through  the  sphincter  ani)  in  which  only  the 
outer  fibers  of  the  sphincter  muscle  are  injured.  In  this 
injury  partial  incontinence  results.  The  woman  may  be 
able  to  control  feces  when  the  movements  are  hard,  but 
loses  control  over  liquid  feces  and  flatus. 

There  is  no  loss  of  support  of  the  pelvic  floor,  and  the 
indication  for  operation  is  the  partial  incontinence.  The 
operation  is  performed  in  a  way  similar  to  that  already 
described  for  complete  laceration.  The  ends  of  the  rup- 
tured fibers  of  the  sphincter  muscles  are  usually  indicated 
by  a  slight  depression  on  the  overlying  skin  or  mucous 
membrane. 

I/aceration  in  One  or  Both  Vaginal  Sulci. — In 
this  form  of  injury  the  tear  takes  place  not  in  the  median 
line,  but  in  the  direction  of  the  vaginal  sulci  or  furrows. 
The  left  sulcus  is  usually  the  more  deeply  torn. 

In  this  form  of  laceration  the  sphincter  ani  muscle 
usually  escapes  injury;  the  tear  is  directed  toward  the 
ischio-rectal  fossa,  and  the  rectum  and  anus  are  pushed  to 
one  side.  The  structures  of  importance  that  are  injured 
are  the  fascia,  the  levator  ani  muscle,  the  sphincter  mus- 
cle of  the  vagina,  and  perhaps  the  transverse  perineal 
muscle.  All  the  supporting  structures  of  the  perineum  and 
of  the  posterior  vaginal  wall  are  injured.  If  the  lacera- 
tion be  bilateral,  complete  loss  of  support  of  the  perineum 
and  the  posterior  vaginal  wall  results,  and  if  the  condi- 
tion be  untreated,  all  the  disastrous  consequences  of  loss 
of  support  of  the  perineum  occur — prolapse  of  the  vagina, 
of  the  uterus,  and  of  the  other  pelvic  organs. 

It  is  unusual  that  this  form  of  laceration  is  entirely 
limited  to  one  sulcus,  though  one  is  usually  more  involved 
than  the  other.  When  the  injury  is  limited  to  one  side, 
the  perineum  is  still  supported  by  the  muscles  and  fascia 
upon  the  other  side,  and  the  tendency  to  prolapse  is  not 
so  marked. 

The  nature  of  this  injury  may  always  be  detected  by 


74 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


examination  after  labor.  The  anterior  vaginal  wall 
should  be  elevated  by  a  retractor,  and  the  posterior  wall 
should  be  carefully  examined.  An  external  tear  of  the 
skin,  generally  in  the  median  line,  usually  accompanies 
laceration  in  the  sulci;  that  is,  the  lacerations  in  the  sulci 
converge  toward  the  fourchette. 

The  immediate  operation  should  always  be  performed. 
The  torn  sulci  should  be  closed  by  sutures  introduced  on 
the  posterior  vaginal  wall  (Fig.  43),  and  the  external  tear 


Fig.  43. — Sutures    introduced  for  the  closure  of  a  recent  perineal  laceration  in 

the  sulci. 


should  be  closed  by  sutures  introduced  as  in  the  first  form 
of  injury  to  the  perineum,  already  described. 

If  this  form  of  perineal  injury  is  not  repaired  by  the 
immediate  operation,  cicatrization  takes  place,  and  the 
tears  in  the  mucous  membrane  and  in  the  skin  become 
healed.  The  fascia  retracts,  and  the  integrity  of  the  sup- 
porting planes  of  fascia  is  destroyed.  The  torn  muscles, 
the  inner  fibers  of  the  levator  ani  and  the  sphincter  vag- 
inae, also  retract  and  cease  to  furnish  any  support  to  the 
perineum.  In  health  these  muscles  embrace  the  lower 
portion  of  the  posterior  vaginal  wall  like  a  sling,  draw- 


INJURIES  TO  THE  PERINEUM.  75 

ing  it  toward  the  symphysis  pubis;  after  laceration  in  the 
sulci  the  support  of  one  or  both  of  the  arms  of  the  sling 
is  destroyed. 

The  scars  upon  the  mucous  membrane  and  on  the  skin 
in  time  become  faint,  with  difficulty  perceptible.  By 
elevating  the  anterior  vaginal  wall  and  closely  inspecting 
the  posterior  wall  immediately  within  the  ostium  vaginae 
we  may  detect  a  fine  irregular  white  line  running  in  the 
direction  of  the  vaginal  sulcus  and  dividing  the  normal 
transverse  ridges  and  furrows  of  the  vaginal  mucous 
membrane.  This  is  the  only  sign  of  former  injury  to 
the  vaginal  mucous  membrane.  The  injury  to  the  under- 
lying structures — the  supporting  structures  of  the  peri- 
neum, the  muscles  and  the  fascia — is  indicated  by  certain 
characteristic  and  unmistakable  signs.  These  signs  are 
best  recognized  after  a  careful  study  of  the  normal  unin- 
jured perineum. 

If  an  uninjured  woman  be  placed  in  the  lithotomy 
position  and  the  perineal  region  be  carefully  examined, 
we  observe  the  following  points: 

The  anus  is  not  prominent:  it  is  drawn  upward  and 
forward;  the  anal  cleft  is  deep. 

The  perineum,  or  the  surface  between  the  anus  and  the 
fourchette,  is  shallow;  the  distance  from  the  anus  to  a 
fixed  point  like  the  external  meatus  is  relatively  short: 
this  surface  is  more  or  less  convex,  showing  muscular 
tonicity. 

If  the  labia  are  separated,  it  will  be  observed  that  the 
anterior  and  posterior  vaginal  walls  are  in  close  apposi- 
tion. If  the  woman  is  made  to  strain  or  to  bear  down, 
the  vaginal  walls  appear  to  come  into  close  contact;  the 
perineum  is  pushed  directly  downward,  and  becomes  more 
prominent  under  the  increased  intra-abdominal  pressure, 
but  there  is  no  tendency  to  eversion  or  rolling  out  of  the 
vaginal  walls. 

If  the  vulva  is  pricked  with  a  needle,  reflex  muscular 
action  is  immediately  observed:  the  anus  is  drawn  still 
more  upward  and  forward;  the  perineum  is  shortened; 


76        A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

the  ostium  vaginae  is  closed  more  firmly  by  the  draw- 
ing forward  of  the  posterior  margin  of  the  opening. 
The  test  shows  that  the  muscles  supporting  the  perineum 
are  intact. 

If  the  finger  be  introduced  into  the  vagina  and  be 
pressed  backward  and  outward  in  either  vaginal  sulcus, 
resisting  structures  are  felt.  There  seems  to  be  a  band, 
perhaps  half  an  inch  in  breadth,  immediately  within  the 
ostium  vaginae,  that  holds  forward  the  perineum  and  the 
posterior  vaginal  wall  and  resists  the  pressure  of  the 
finger. 

Compare  these  characteristic  features  of  the  uninjured 
perineum  with  what  we  observe  in  a  woman  in  whom 
there  has  been  an  untreated  laceration  of  the  perineum 
in  the  vaginal  sulci.  Here  the  supporting  structures  of 
the  perineum  have  been  destroyed. 


ABC 

Fig.  44. — Diagram  showing  the  shng  of  muscle  and  fascia  supporting  the 
perineum  and  the  posterior  vaginal  wall.  In  A  the  parts  are  intact;  in  B  there 
has  been  a  laceration  in  the  left  vaginal  sulcus ;  in  c  there  has  been  a  laceration 
in  both  sulci;  a  suture  has  been  introduced  on  the  right  side. 

The  anal  cleft  is  shallow.  The  anus  is  prominent;  the 
surrounding  structures  present  the  appearance  of  relaxa- 
tion. The  perineum  is  deep;  the  distance  from  the  anus 
to  the  external  meatus  is  longer;  the  anus  has  really 
dropped  back.  The  skin-surface  of  the  perineum  is  flat 
and  relaxed. 

If  the  labia  are  separated,  the  anterior  and  posterior 
vaginal  walls  will  not  be  found  in  close  apposition.     The 


INJURIES  TO  THE  PERINEUM. 


77 


ostium  vaginae  is  patulous  and  gaps  open  (Fig.  45).  If 
the  woman  is  made  to  bear  down,  the  anterior  and  pos- 
terior vaginal  walls  are  not  pushed  together;  they  are 
rolled  out  and  protrude  through  the  ostium  vaginae. 

If  the  vulva  is  pricked  with  a  needle,  the  woman  draws 
herself  away  ;  there  is  no  reflex  muscular  action,  closing 
the  vagina  and  drawing  up  the  anus.  The  muscles  of 
the  perineum  have  been  destroyed. 

If  the  finger  is  introduced  in  the  vagina  and  pressed 
backward  and  outward  in 
either  vaginal  sulcus,  the 
tissues  are  yielding  and 
soft  ;  no  supporting  sling 
of  muscle  and  fascia  is 
felt. 

These  phenomena  have 
an  unmistakable  mean- 
ing, and  indicate  clearly 
the  loss  of  the  support- 
ing structures  of  the  pel- 
vic floor. 

The  student  should 
acquire  familiarity  with 
these  tests  by  repeated 
experiments  on  injured 
and  uninjured  women. 
It  will  easily  be  under- 
stood that  the  same  phe- 
nomena characterize  the 
foiirth  form  of  injury  to 
the  perineum — the  sub- 
cutaneous laceration. 

A  perineum  in  this  con- 
dition is  often  said  to  be 
relaxed.       It    is    relaxed 
because  the   muscular   and    fascial   supports  have   been 
destroyed. 

Treatmeni. — The  treatment  is  directed  to  the  restora- 


FlG.  45. — An  old  laceration  of  the 
perineum  in  both  sulci.  Rectocele.  The 
mouth  of  the  vagina  is  held  open  to  show 
the  appearance  of  the  parts  before  opera- 
tion :  a,  apex  of  the  rectocele. 


78 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


tion  of  these  supports.  Each  vaginal  sulcus  must  be 
denuded,  so  that  the  condition  existing  in  the  recent 
injury  (Fig.  43)  is  reproduced,  and  the  sutures  must  be 
passed  so  that  the  retracted  muscles  and  the  fascia  are 
brought  back  to  their  normal  attachments.  The  best 
method  of  operating  for  this  condition  has  been  devised 
by  Emmet. 

Emmefs    Operation  (Figs.    45-55). — When    the    labia 


Fig.  46. — The  rectocele  is  seized 
with  the  tenaculum  at  a,  and  is  drawn 
to  the  right,  exposing  the  left'  vaginal 
sulcus,  a,  b,  c,  which  must  be  denuded. 
The  point  b  should  be  secured  with  a 
tenaculum  before  denuding. 


Fig.   47- 


-Method   of   denuding   the 
sulcus. 


have  been  separated,  it  will  be  observed  that  there  is  a 
bulging  or  prominence  of  the  lower  portion  of  the  poste- 
rior vaginal  wall,  which  is  called  a  rectocele.     The  most 


INJURIES  TO  THE  PERINEUM. 


79 


prominent  point  or  the  apex  of  the  rectocele  should  be 
held  by  a  tenaculum  or  by  a  silk  ligature  passed  imme- 
diately beneath  the  mucous  membrane. 

This  point  should  be  such  that  it  may  without  undue 
traction  be  drawn  to  either  orifice  of  the  vulvo-vaginal 
glands. 

If  the  apex  of  the  rectocele  is  drawn  to  one  side,  there 


"Fig.  48. — The  left  sulcus  denuded. 


Fig.  49. — Both  sulci  denuded. 


-is  formed  on  the  other  side  a  triangular  area  (Fig.  46,  «, 
.b^  c).  The  base  of  this  area  (<2,  c)  is  at  the  ostium  vaginae. 
'The  inner  side  (^,  b)  runs  along  the  side  of  the  rectocele. 
The  outer  side  {b^  c)  runs  along  the  lateral  vaginal  wall. 
The  apex  b  is  approximately  the  highest  point  of  the 
tear  in  the  sulcus.  The  angle  c  is  immediately  below 
the  orifice  of  the  vulvo-vaginal  gland.  The  angle  b  is 
;fixed  by  a  tenaculum  held  by  an  assistant,  and  the  tri- 


8o 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


anofular  area  is  denuded.  The  denuded  area  does  not 
correspond  exactly  with  the  original  tear  in  the  sulcus, 
but  the  denudation  exposes  the  sulcus,  so  that  sutures 
may  be  passed  in  such  a  way  as  to  include  the  muscles 
and  fascia.  The  sulcus  on  the  opposite  side  is  then 
denuded  in  a  similar  manner,  and  the  lower  face  of  the 
rectocele  is  denuded.  It  is  best  to  begin  the  denudation 
by  seizing  with  tissue-forceps  the  mucous  membrane  of 


Fig.  50. — Introduction  of  the  su- 
tures. The  point  of  the  emerging 
needle  is  held  by  the  tenaculum. 


Fig.  51. — Sutures  introduced  in  both 
sulci. 


the  posterior  vaginal  wall  at  the  ostium  vaginae,  at  the 
junction  of  skin  and  mucous  membrane,  and  to  remove 
contiguous  strips  of  tissue  by  cutting  upward  toward  the 
apex  of  the  vaginal  sulcus  (Fig.  47). 

In  the  denudation  no  skin  is  sacrificed.  The  denuda- 
tion is  not  carried  below  the  line  of  junction  of  vaginal 
mucous  membrane  with  skin. 


INJURIES  TO  THE  PERINEUM.  8 1 

Each  sulcus  is  closed  by  sutures  separately,  as  in  the 
immediate  operation.  The  first  suture  is  passed  across 
the  upper  angle  b. 


Fig.  52. — Method  of  securing  sutures 
with  perforated  shot. 


Fig.  53. — Both  sulci  are  closed. 
The  support  of  the  perineum  is  re- 
stored. The  posterior  wall  of  the  va- 
gina is  brought  forward.  The  rectocele 
is  cured. 


The  second  suture  is  introduced  about  an  eighth  of  an 
inch  from  the  edge  of  the  mucous  membrane  on  the  left 
vaginal  wall,  is  passed  backward,  downward,  and  out- 
ward so  as  to  grasp  retracted  muscular  fibers,  and  is  made 
to  emerge  at  the  bottom  of  the  sulcus.  It  is  then  re- 
introduced and  passed  forward  between  the  mucous  mem- 
brane of  the  rectum  and  the  denuded  surface,  and  some- 
what upward,  to  emerge  on  the  edge  of  the  mucous 
membrane  of  the  rectocele.      A  third  and,   if  necessary. 


82 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


a  fourth  suture  are  passed  in  a  similar  manner.     Similar 
sutures  are  then  passed  to  close  the  right-hand  sulcus. 

The  sutures  thus  far  introduced  are  sufficient  to  close 
the  sulci,  and  therefore  to  restore  the  supporting  struc- 
tures   of    the   perineum.      The   remaining  sutures    are 


Fig.  54. — Sutures  for  closing  the  super- 
ficial perineum  and  fourchette.  The  an- 
terior suture  is  called  the  "  crown  suture." 


Fig.  55. — Emmet's  operation  of 
perineorrhaphy  completed.  Com- 
pare this  figure  with  that  represent- 
ing the  condition  of  the  parts  before 
operation  (Fig.  45). 


merely  to  close  the  skin-perineum.  The  first  of  these 
sutures  is  called  the  crown  suture.  The  needle  is  intro- 
duced on  the  cutaneous  aspect  of  the  perineum,  at  the 
anterior  end  of  the  lateral  denudation.  It  passes  out- 
side of  the  denuded  area,  and  emerges  within  the  de- 
nuded area,  at  the  edge  of  the  mucous  membrane  of  the 
vaginal  wall,   immediately  below  the  last  suture   of  the 


INJURIES  TO  THE  PERINEUM.  83 

sulcus.  It  is  then  passed  so  as  to  transfix  the  rectocele 
beneath  the  mucous  membrane,  and  across  the  lateral 
denudation  on  the  other  side.  When  this  suture  is  shotted 
the  fourchette  is  restored.  A  second  suture  behind  the 
crown  suture  is  usually  necessary  to  complete  the  clos- 
ure of  the  skin-perineum. 

The  sutures  in  the  sulci  are  shotted  first,  then  the  ex- 
ternal sutures  are  shotted. 

The  second  and  third  varieties  of  perineal  injury  are 
sometimes  found  associated  in  women  who  have  borne 
more  than  one  child,  the  injuries  having  in  all  probability 
occurred  at  different  labors.  In  such  a  case  the  sulci 
should  be  denuded  and  closed  as  already  described,  and 
then  the  skin-perineum  and  the  sphincter  ani  should  be 
repaired. 

Subcutaneous  I/aceration  of  the  Muscles  and 
Fascia. — The  fourth  variety  of  injury  to  the  perineum — 
subcutaneous  laceration  of  the  muscles  and  fascia — is  not 
uncommon.  The  structures  which  compose  the  pelvic 
floor  are  of  different  degrees  of  elasticity,  and  sometimes 
the  mucous  membrane  and  skin  at  the  vaginal  outlet  will 
stretch,  and  not  rupture,  before  the  advancing  head  of 
the  child,  while  the  underlying  structures — the  muscles 
and  fascia — may  give  way.  Therefore  the  injury  is  said 
to  be  a  subcutaneous  laceration.  The  sphincter  ani  is 
never  involved  in  this  form  of  injury.  The  injury  always 
takes  place  in  the  direction  of  the  vaginal  sulci,  and  the 
supporting  muscles  of  the  pelvic  floor  and  the  planes  of 
fascia  are  the  structures  which  are  torn.  The  disability 
is  exactly  the  same  as  in  the  third  variety  of  perineal 
tear,  with  the  absence  of  laceration  of  mucous  membrane 
and  skin. 

It  is  not  to  be  expected  that  this  injury  will  be  posi- 
tively recognized  at  the  time  of  labor,  and  therefore  the 
immediate  operation  cannot  be  applied  to  it.  The  condi- 
tion is  often  described  as  relaxation  of  the  perineum. 
The  disabilities  following  this  injury,  and  the  tests  by 
which  it  may  be   recognized,    are  identical  with  those 


84        A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

already  described  under  old  lacerations  in  the  sulci. 
The  treatment  is  also  the  same.  The  vaginal  sulci  must 
be  denuded  as  though  the  mucous  membrane  had  in 
reality  been  torn,  and  the  sutures  must  be  introduced  in 
such  a  way  as  to  bring  back  the  muscles  and  the  fascia 
to  the  former  attachments. 


CHAPTER   VII. 


RESULTS  OF  LACERATION  OF  THE  PERINEUM. 

Rectocele. — A  rectocele  (Fig.  56)  is  the  tumor  formed 
by  the  protrusion  of  the  lower  part  of  the  posterior  vag- 
inal wall  into  the  vagina  or 
through  the  ostium  vaginse. 
The  condition  is  due  to  a 
prolapse  of  the  posterior 
vaginal  wall,  and  is  caused 
by  the  loss  of  the  support 
of  the  perineum,  usually 
the  result  of  laceration  at 
childbirth.  Sometimes  the 
mucous  membrane  of  the 
vagina  alone  prolapses,  the 
anterior  wall  of  the  rectum 
remaining  in  place.  Usu- 
ally, however,  the  anterior 
rectal  wall  and  the  posterior 
vaginal  wall  protrude  to- 
gether. If  the  rectocele 
is  not  so  extensive  as  to 
protrude  through  the  os- 
tium, the  woman  may  be 
unaware  of  its  existence.  In  many  cases,  however,  the 
prolapsing  vaginal  wall  protrudes  at  the  vulvar  cleft  when 
the  woman  is  erect,  or  when  she  strains  at  stool  or  per- 
forms work  requiring  heavy  lifting.  The  woman  often 
says  that  under  such  circumstances  the  "womb"  pro- 
trudes. On  account  of  the  accompanying  prolapse  of  the 
anterior  rectal  wall  the  passage  of  feces  does  not  take 
place  in  the  normal  direction,  but  the  fecal  mass  is  forced 

85 


Fig.  56. — Rectocele  and  cystocele. 


86         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

into  the  pouch  of  the  anterior  wall  of  the  rectum,  and 
straining  efforts  push  it  forward  into  the  vagina.  The 
woman  says  she  feels  as  though  the  passages  were  about 
to  take  place  through  the  vagina.  This  discomfort  is 
relieved  by  pressing  the  rectocele  back  with  the  finger 


Fig.  57. — Median  sagittal  section  of  the  pelvis  of  a  woman  in  whom  there 
has  been  a  laceration  of  the  perineum  in  the  sulci,  with  rectocele  and  cysto- 
cele.     The  vagina  is  no  longer  a  closed  slit. 

during  defecation.  Accumulation  of  feces  in  the  rectal 
pouch  may  result  in  inflammation  or  ulceration.  The 
condition  is  readily  recognized  by  introducing  a  finger 
into  the  rectum,  when  it  will  be  found  to  enter  the 
rectocele. 

A  rectocele  is  cured  by  Emmet's  operation,  which 
restores  the  support  of  the  perineum  and  the  posterior 
wall  of  the  vagina. 

Cystocele. — A  cystocele  is  a  tumor  formed  by  the  pro- 


RESULTS  OF  L  ACER  A  TION  OF  THE  PERINEUM.      87 

trusion  of  the  lower  part  of  the  anterior  vaginal  wall  into 
the  vagina  or  through  the  ostium  (Fig.  56).  The  pro- 
lapse of  the  vaginal  wall  is  accompanied  by  prolapse  of 
the  posterior  wall  of  the  bladder.  A  sound  introduced 
into  the  bladder  through  the  urethra  will  be  found  to 
enter  the  cystocele.  This  test,  and  the  soft,  reducible 
character  of  the  cystocele  tumor,  enable  us  to  diagnos- 
ticate between  cystocele  and  cyst  of  the  anterior  vaginal 
wall.  The  condition  is  caused  b)'  a  loss  of  the  support 
of  the  anterior  vaginal  wall  that  is  furnished  by  the  pos- 
terior wall  and  the  perineum. 

In  a  case  of  cystocele  residual  urine  often  remains  in 
the  pouch  of  the  bladder- wall.  In  some  cases  the  woman 
learns  that,  in  order  to  empty  the  bladder,  it  is  necessary 
for  her  to  push  the  cystocele  upward  and  forward  at  every 
act  of  micturition.  The  result  of  this  inability  to  empty 
the  bladder  is  decomposition  of  the  urine  and  resulting 
cystitis. 

Many  cases  of  so-called  irritable  bladder  and  chronic 
cystitis  are  caused  primarily  by  laceration  of  the  peri- 
neum, which  produces  cystocele  or  prolapse  of  the  pos- 
terior wall  of  the  bladder;  and  such  cases  can  be  cured 
only  by  curing  the  cystocele. 

A  cystocele  varies  much  in  size.  Every  long-standing 
case  of  laceration  of  the  perineum  in  the  sulci  presents 
a  certain  degree  of  prolapse  of  the  anterior  vaginal  wall. 
The  tumor  may  remain  within  the  vagina  and  be  rendered 
prominent  only  upon  efforts  at  straining,  or  it  may  pro- 
trude through  the  vulva  as  a  mass  the  size  of  a  duck's 

As  a  cystocele  is  caused  by  laceration  of  the  perineum, 
it  can  be  cured  only  by  repair  of  this  laceration.  The 
most  important  part  of  the  treatment,  therefore,  is  peri- 
neorrhaphy, which  should  always  be  performed.  Usually 
this  operation  is  sufficient.  If  the  anterior  wall  of  the 
vagina  is  supported,  the  tissues  will  recover  their  tonicity 
and  contract,  and  the  tumor  will  disappear. 

In  some  cases,  however,  where  the  mucous  membrane 


88 


A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


Fig.  58. — Oval    ilemulation   for   cysto- 
cele :  sutures  introduced. 


of  the  anterior  vaginal  wall 
has  become  much  stretched 
and  redundant  in  the  nor- 
mal-sized vagina,  it  is  ad- 
visable, in  addition  to  the 
perineorrhaphy,  to  perform 
a  plastic  operation  on  the  an- 
terior wall  in  order  to  dimin- 
ish the  area  of  the  vaginal 
mucous  membrane.  Such 
an  operation  is  called  an- 
terior colporrhaphy.  A  va- 
riety of  operations  of  this 
kind  have  been  invented. 
The  various  forms  are  mod- 


FlG.  59. — Stoltz's  operation  for  cystocele. 

ified  according  to  the  requirements  of  the  case  and  the 
whims  of  the  operator.      In  one  form  of  operation  an 


RESULTS  OF  LACERATION  OF  THE  PERINEUM.      89 


oval  area  is  denuded  (Fig.  58),  and  the  edges  are  brought 
together  by  interrupted  sutures  passed  beneath  the  whole 
denuded  surface. 

In  Stoltz's  operation  (Fig.  59)  a  circular  area  is  de- 
nuded over  the  most  prominent  part  of  the  cystocele, 
and  a  single  suture  of  strong  silk  is  passed  around 
the  circumference  like  the  puckering-string  of  a  pouch; 
the  center  of  the  circle  is  then  pushed  upward  with 
a  sound,  and  the  puckering-string  is  drawn  tight  and 
tied. 

As  the  transverse  measurement  of  the  vagina  is  greater 
in  the  upper  than  in  the  lower  part,  an  operation  by  which 
a  greater  amount  of  the  excess  of  tissue  is  taken  in  above 
than  below  is  often  desirable.  Such  an  operation  is  rep- 
resented in  Fig.  60.  Two  strips,  about  one-third  to  one- 
half  inch  in  breadth,  are  denuded  on  each  side  of  the 
anterior  wall,  extending  from  the  position  of  the  internal 
urinary  meatus  upward  toward 
the  lateral  vaginal  fornices. 
The  length  of  these  strips  va- 
ries with  the  case,  and  depends 
upon  the  size  of  the  upper  por- 
tion of  the  vagina.  It  is  often 
desirable  to  carry  the  denuda- 
tion to  the  level  of  the  external 
OS.  The  denuded  surfaces  are 
brought  into  apposition  by- 
interrupted  sutures.  By  this 
operation  the  whole  caliber  of 
the  vagina  is  narrowed  from 
above  downward.  The  degree 
of  divergence  of  the  denuded 
strips  may  be  determined  by 
seizing  portions  of  tissue  with  tenacula  upon  each  side 
and  bringing  them  together,  thus  determining  the  amount 
of  tension  which  will  be  put  upon  the  sutures.  The  ope- 
ration of  anterior  colporrhaphy  must  always  be  accom- 
panied by  perineorrhaphy.    The  anterior  operation  should 


Fig.  60. — Sims'  operation  for 
cystocele. 


go         A   TEXT-BOOK  OF  DISEASES  OF  WOMEM. 

be  performed  first.     The  woman  should  be  placed  in  the 
Sims  or  the  dorsal  position. 

Knterocele. — Enterocele,  or  entero-vaginal  hernia,  is 
a  rare  condition.  It  consists  of  a  hernia,  or  prolapse,  of 
the  intestine  into  the  vaginal  canal.  Two  forms  of  the 
disease  have  been  described — the  anterior  and  the  poste- 
rior. The  latter  is  the  more  common.  In  the  posterior 
variety  one  or  more  loops  of  the  intestine,  or  the  omen- 
tum, reach  the  bottom  of  Douglas's  pouch  and  push 
the  posterior  vaginal  wall  forward,  so  that  it  encroaches 
upon  the  vaginal  canal  and  in  some  cases  protrudes  from 
the  ostium  vaginae. 

The  causes  of  this  disease  are  not  known.  It  is  prob- 
ably favored  by  loss  of  support  of  the  perineum  and  the 
vaginal  walls.  An  unusually  deep  pouch  of  Douglas 
would  predispose  a  woman  to  this  condition. 

In  the  anterior  form  of  the  disease  the  hernia  occurs  at 
the  bottom  of  the  vesico-uterine  pouch. 

The  posterior  enterocele  may  be  distinguished  from 
rectocele  by  introducing  a  finger  into  the  rectum  and 
one  into  the  vagina,  when  the  prolapsed  intestine  or 
omentum  may  be  felt  between  the  anterior  rectal  wall 
and  the  posterior  vaginal  wall.  The  condition  may  be 
distinguished  from  vaginal  cyst  by  percussion  and  pal- 
pation. 

In  the  treatment  of  enterocele  any  existing  injury  to 
the  perineum  should  be  repaired,  and  the  vagina  should 
be  narrowed  by  one  of  the  plastic  operations  already  de- 
scribed. Great  care  should  be  taken  not  to  injure  with 
the  needle  the  intestine  underlying  the  vaginal  wall. 

Subinvolution  of  the  Vagina. — It  should  be  remem- 
bered, in  connection  with  the  subject  of  prolapse  of  the 
vaginal  walls  as  a  result  of  loss  of  the  perineal  support, 
that  there  is  always  present,  also,  a  condition  of  subin- 
volution of  the  vagina.  During  pregnancy  all  the  ele- 
ments of  the  vagina  undergo  a  physiological  hypertrophy 
analogous  to  that  which  occurs  in  the  uterus.  After 
labor  the  vagina  normally  undergoes  certain  changes  by 


RESULTS  OF  LACERATION  OF  THE  PERINEUM.      91 

which  it  is  again  approximately  restored  to  the  dimen- 
sions, shape,  etc.  that  existed  before  pregnancy.  This 
change  is  called  the  involution  of  the  vagina.  Anything 
that  arrests  this  process  of  involution  produces  a  state  of 
subinvolution  of  the  vagina  ;  this  structure  is  then  found 
much  larger  and  more  relaxed  than  normal,  and  a  cer- 
tain hypertrophy  of  all  the  elements  of  the  vaginal  walls 
persists.  Such  subinvolution  of  the  vagina  is  caused  by 
the  various  pelvic  lacerations,  which,  by  causing  loss  of 
support  to  the  pelvic  vessels,  result  in  a  state  of  passive 
congestion. 

These  redundant  vaginal  structures  usually  disappear 
and  contraction  takes  place  after  the  operation  of  perin- 
eorrhaphy. In  some  cases,  however,  when  the  vagina  is 
very  much  larger  and  more  relaxed  than  normal,  it  is 
advisable  to  remove  some  of  the  excess  of  tissue  by  a 
plastic  operation  on  the  anterior  wall  similar  to  that 
described  for  the  relief  of  cystocele. 


CHAPTER  VIII. 

THE   POSITION   OF  THE   UTERUS   AND    THE   MECH= 
ANISM  OF  ITS  SUPPORT. 

The  uterus  normally  lies  with  its  anterior  surface  in 
contact  with  the  posterior  aspect  of  the  bladder,  no  in- 
testines intervening.  The  absolute  and  relative  posi- 
tions of  the   uterus  depend  upon  the  degree  of  disten- 


FlG.  6i. — Normal  range  of  position  of  the  uterus,  depending  upon  the  distention 

of  the  bladder. 

tion  of  the  bladder  and  the  position  of  the  woman.  The 
uterus  is  pushed  backward  and  the  fundus  is  turned  up- 
ward by  distention  of  the  bladder.  When  the  woman  is 
erect  the  uterus  lies  at  a  slightly  lower  level  than  when 
the  woman  is  on  her  back,  and  the  intra-abdominal  pres- 

92 


POSITION  OF  THE  UTERUS.  93 

sure  acting  upon  the  posterior  surface  of  the  fundus  turns 
the  uterus  more  forward,  so  that  the  fundus  lies  nearer 
the  symphysis  pubis.  Fig.  6i  shows  about  the  normal 
range  of  position. 

It  may  be  said  that  in  the  normal  woman  the  long  axis 
of  the  uterus  is  approximately  perpendicular  to  the  long 
axis  of  the  vagina  (Fig.  62). 


Fig.  62. — Median  sagittal  section  of  the  normal  female  pelvis. 

The  uterus  does  not  surmount  the  vagina  with  the  axes 
of  the  two  structures  in  the  same  line,  as  is  shown  iu  some 
anatomical  plates. 

The  cervix  looks  backward  toward  the  coccyx,  from 
the  tip  of  which  it  is  situated  0.6  to  1.2  inches. 

The  uterus  is  maintained  in  position  by  a  variety  of 
factors.  The  ligaments,  which  have  been  described,  are 
eight  in  number — broad  ligaments,  round  ligaments, 
utero-sacral  and  utero-vesical  ligaments. 


94         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

With  the  exception  of  the  round  ligaments,  which  are 
muscular  structures,  the  uterine  ligaments  are  formed  by 
peritoneal  folds,  including  connective  tissue,  blood-ves- 
sels, lymphatics,  and  a  small  amount  of  unstriped  muscle. 

When  the  woman  is  erect  the  insertions  and  origins  of 
the  various  uterine  ligaments  lie  in  the  same  horizontal 
plane.  The  insertion  of  no  ligament  is  higher  than  its 
origin  in  the  uterus;  therefore  these  ligaments  do  not  act 
as  suspensory  ligaments  when  the  uterus  is  in  its  normal 
position.  The  truth  of  this  fact  is  repeatedly  demon- 
strated at  operations.  If  the  cervix  be  caught  with  a 
tenaculum  when  the  woman  is  on  her  back,  the  uterus 
may,  with  but  very  little  force,  be  drawn  downward 
toward  the  ostium  vaginae  to  the  extent  of  one  or  two 
inches;  and  similarly,  by  a  slight  digital  pressure  on  the 
cervix,  the  uterus  may  be  pushed  upward  from  one  to 
two  inches  above  its  normal  position. 

The  ligaments  of  the  uterus  act  as  guys.  They  steady 
it,  and  prevent  too  great  lateral  and  fore-and-aft  move- 
ment; they  do  not,  when  the  uterus  is  in  its  normal  posi- 
tion or  at  its  normal  level,  sustain  it  against  the  force  of 
gravity.  When,  however,  the  uterus,  for  any  reason, 
falls  an  inch  or  more  below  its  normal  level,  the  uterine 
ligaments  become  suspensory  in  character. 

In  the  normal  woman  the  vagina  is  always  closed.  As 
has  already  been  said,  it  is  a  slit  in  the  pelvic  floor,  val- 
vular in  character;  consequently  the  abdominal  and  pelvic 
viscera  may  be  considered  to  be  contained  in  a  closed 
vessel,  in  woman  as  well  as  in  man.  The  uterus  floats  in 
this  closed  vessel  at  a  level  which  is  consistent  with  its 
own  specific  gravity.  If,  for  any  reason,  the  specific 
gravity  of  the  uterus  were  increased,  it  would  sink  below 
the  level  at  which  it  is  normally  situated. 

Since,  normall}',  there  is  no  tendency  in  the  uterus  to 
change  its  position,  the  pressure  upon  it  must  be  equal  in 
all  directions.  The  subject  may  perhaps  be  better  under- 
stood by  referring  to  a  few  simple  facts  in  hydrostatics. 
If  a  fluid  contained  in  a  closed  vessel  be  in  a  condition 


POSITION  OF  THE  UTERUS. 


95 


of  equilibrium  so  that  its  various  particles  are  at  rest, 
then  the  pressure  upon  any  particle  is  equal  and  opposite 
in  all  directions  (Fig.  63);  otherwise  the  particles  would 


Fig.   63. — Vessel   containing  fluid  in  equilibrium.     The   arrows  indicate  the 
direction  of  the  pressure  at  various  points. 

not  be  in  equilibrium,  but  would  move.  The  bottom  of 
such  a  vessel,  however,  is  not,  like  the  particles  of  the 
fluid,  surrounded  on  all  sides  by  the  fluid,  but  above  it  is 
the  fluid,  and  below  it  is  the  atmospheric  air.  Any  point 
upon  the  bottom  of  the  vessel  is  subjected  to  a  downward 
pressure  equal  to  the  weight  of  the  column  of  fluid  above 
the  point;  this  downward  pressure  is  resisted  by  the 
strength  of  the  material  composing  the  vessel.  If  this 
material  be  yielding  or  elastic  in  character,  the  pressure 
above  will  make  the  bottom  protrude  to  a  certain  extent. 
A  particle  within  the  fluid  (like  X  immediately  above  the 
bottom  of  the  vessel)  will  be  subjected  to  a  downward 
pressure  equal  to  the  weight  of  the  column  of  fluid  above 
it;  but  this  pressure  will  be  counterbalanced  not  by  any 
strength  in  the  particle,  but  by  a  counter-force  acting 
from  below  equal  and  opposite  to  that  acting  from  above. 
A  similar  state  of  things  exists  in  the  female  pelvis. 
The  uterus  floats  at  a  certain  level,,  and  the  intra-abdom- 
inal pressure  acting  from  above  is  counterbalanced  by  an 


96        A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

equal  force  acting  from  below,  while  the  floor  or  bottom 
of  this  vessel  (part  of  which  is  the  perineum)  is  subjected 
to  a  force  from  above  equal  to  the  intra-abdominal  pres- 
sure, and  this  force  is  opposed  only  by  the  strength  of  the 
perineum  (see  Fig.  64). 


Fig.  64. — Diagram  representing  the  directions  of  the  intra-abdominal  pressure 
upon  the  uterus  in  the  uninjured  woman. 

If  the  vagina  were  an  open  tube  admitting  air,  so  that 
the  uterus  above  was  in  contact  with  the  contents  of  the 
pelvic  vessel  and  below  with  atmospheric  air,  then  the 
condition  of  things  would  be  altered.  In  this  case  the 
uterus  would  in  reality  become  part  of  the  floor  of  the 
vessel,  and  would  be  subjected  to  a  pressure  from  above 
equal  to  the  intra-abdominal  pressure,  and  to  this  pres- 
sure would  be  opposed  only  the  strength  of  the  uterus 
and  its  attachments.  Such  a  state  of  things  occurs  when 
the  perineum  is  torn  and  the  vagina  becomes  a  patulous 
open  canal,  and  not  a  closed  slit.  Therefore  when  the 
opening  of  the  vagina  is  torn  and  air  constantly  enters 
the  vaginal  canal,  the  normal  hydrostatic  equilibrium  of 
the  pelvic  contents  is  destroyed,  the  resultant  of  the 
forces  acting  upon  the  uterus  is  downward,  and  the 
organ  has  a  tendency  to  fall  or  to  prolapse  (Fig.   65). 

The  normal  perineum  and  vagina  do  not  sustain  the 


POSITION  OF  THE  UTERUS. 


97 


uterus  by  furnishing  a  mechanical  support  from  below, 
any  more  than  the  bottom  of  a  vessel  sustains  any  single 
particle  of  fluid  floating  in  it. 

When  the  uterus  tends  to  fall  down  or  to  prolapse,  its 
progress  is  opposed  at  a  certain  level  by  its  various  attach- 


FlG.  65. — Diagram  representing  the  direction  of  the  intra-abdominal  pressure  in 
the  woman  with  a  laceration  of  the  perineum. 

ments.  The  ligaments  become  suspensory  in  character  as 
soon  as  their  uterine  attachments  are  below  their  pelvic 
attachments.  The  cellular  tissue,  fat,  blood-vessels,  etc. 
connected  with  the  uterus  restrain  its  downward  motion. 
And,  finally,  this  motion  is  restrained  by  what  has  been 
called  the  ' '  retentive  power  of  the  abdomen, ' '  which  is 
merely  the  atmospheric  pressure  acting  from  below  on 
the  contents  of  a  vessel  the  top  and  sides  of  which  are 
closed. 

Refer  again  to  a  simple  physical  example :  If  a  glass 
tube  be  filled  with  water,  a  finger  placed  over  one  end, 
and  the  tube  inverted,  the  water  will  not  run  out:  it  is' 
sustained  by  atmospheric  pressure  acting  from  below. 
If  the  finger  be  removed,  atmospheric  pressure  also  acts 
from  above,  and  the  water  will  fall.  If  a  hole  be  made 
in  the  side  of  the  tube,  atmospheric  pressure  will  act 
through  it,  and  the  water  below  the  hole  will  fall. 


9^         A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

In  order  that  the  column  of  water  be  sustained,  the 
sides  of  the  tube  must  be  rigid  or  unyielding.  If  the 
sides  of  the  tube  yielded  slightly  to  atmospheric  pres- 
sure, they  would  sink  in  and  a  certain  amount  of  water 
would  escape. 

The  abdorninal  and  pelvic  cavities  in  the  erect  woman 
may  be  considered  as  a  tube  filled  with  fluid  contents. 
The  top  of  the  tube  is  closed  by  the  diaphragm ;  the  sides 
are  the  more  or  less  rigid  abdominal  walls  and  the  back; 
the  floor  is  the  perineum.  When  the  floor  is  destroyed  a 
hole  is  made  in  the  bottom  of  the  tube  :  the  contents  tend 
to  fall,  but  the  fall  is  resisted  by  atmospheric  pressure 
acting  from  below.  If  the  diaphragm  and  the  parietes 
were  rigid  as  glass,  there  would  be  no  prolapse,  any  more 
than  there  is  prolapse  of  the  water  in  the  glass  tube.  If 
the  parietes  yield  somewhat,  the  amount  of  fall  or  pro- 
lapse is  proportional.  Thus  the  retentive  power  of  the 
abdomen  is  dependent  upon  the  strength  or  rigidity  of. 
the  abdominal  walls. 


.    CHAPTER    IX. 
PROLAPSE  OF  THE   UTERUS. 

Prolapse  of  the  uterus  means  a  falling  of  that  organ 
below  its  normal  level.  The  condition  is  popularly 
spoken  of  as  "falling  of  the  womb."  There  are  an 
infinite  number  of  degrees  of  prolapse  of  the  uterus, 
between  the  slightest  descent  on  the  one  hand  and 
complete  protrusion  of  the  organ  from  the  body  on  the 
other  hand.  The  term  "complete  prolapse"  should 
properly  be  applied  to  the  entire  protrusion  of  the 
uterus  outside  of  the  vulva.  This  condition,  however, 
is  most  unusual.  The  term  is  generally  used  to  desig- 
nate those  cases  in  which  the  cervix  alone,  or  the  cervix 
and  part  of  the  body  of  the  uterus,  protrude  from  the 
vulva  (Fig.  66).  In  any  case  of  prolapse  of  the  uterus  it 
is  best  to  describe  in  detail  the  extent  of  the  prolapse  and 
the  other  conditions  present.  Thus,  some  of  the  various 
kinds  of  prolapse  may  be  described  as  follows :  ' '  Pro- 
lapse of  the  uterus,  the  cervix  resting  on  the  pelvic 
floor;"  "prolapse  of  the  uterus,  the  cervix  presenting  at 
the  vulvar  cleft;"  "prolapse  of  the  uterus,  the  cervix 
protruding  about  two  inches  from  the  ostium  vaginse, 
with  elongation  of  the  supra-vaginal  cervix,"  etc. 

Injury  to  the  pelvic  floor  that  allows  air  to  enter  the 
vagina  destroys  the  normal  equilibrium  of  the  pelvic 
contents  and  exposes  the  uterus  to  a  direct  abdominal 
pressure  from  above,  which  is  not  counterbalanced  by  an 
equal  force  from  below,  but  is  opposed  by  the  strength 
of  the  uterus  and  its  attachments  and  the  retentive  power 
of  the  abdomen.  Most  cases  of  prolapse  occur  in  women 
in  whom  the  perineum  has  been  injured  at  childbirth. 

There  are  a  number  of  predisposing  causes  of  uterine 


lOO       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

prolapse  that  permit  the  descent  to  progress  after  the 
uterus  has  begun  to  fall — namely :  Relaxation  of  the 
uterine  ligaments  that  results  from  too  frequent  partu- 
rition, from  old  age,  or  from  tissue-weakness  which  is 
part  of  a  general  condition,  the  uterine  ligaments  sharing 
the  general  feebleness  of  the  other  tissues  and  structures 
of   the  body;   relaxation,   loss  of   rigidity,    or  muscular 


Fig.  66. — Prolapse  of  the  uterus,  the  cervix  protruding  from  the  vulva.     There 
is  a  bilateral  laceration  of  the  cervix. 


weakness  of  the  abdominal  parietes,  which  diminishes 
the  retentive  power  of  the  abdomen;  diminution  of  the 
cellular  tissue  and  the  fat  of  the  pelvis,  such  as  occurs  in 
wasting  disease  or  in  old  age.  Anything  that  suddenly 
increases  the  intra-abdominal  pressure,  such  as  lifting  a 
heavy  weight,  may  cause  acute  prolapse  of  the  uterus. 
In  some  cases  the  uterus  has  suddenly  protruded  from  the 
body  as  a  result  of  heavy  lifting.     In  cases  of  this  cha- 


PROLAPSE  OF  THE  UTERUS.  loi 

racter  it  is  probable  that  the  muscular  supports  of  the 
perineum  have  been  weakened  from  some  cause,  or  that 
the  sudden  increase  of  abdominal  pressure  drives  the 
uterus  downward  before  the  perineal  muscles  have  time 
to  contract  and  close  the  vaginal  outlet.  In  such  cases 
there  is  also  present  rupture  of  the  uterine  ligaments. 
Constant  violent  coughing  has  produced  uterine  prolapse 
in  a  similar  way. 

Extreme  uterine  prolapse  sometimes  occurs  in  a  nullip- 
arous  woman  in  whom  the  perineal  supports  are  natu- 
rally weak.  In  such  women  there  exists  a  condition  of 
relaxation  identical  in  results  with  subcutaneous  lacera- 
tion of  the  perineum. 

Anything  that  increases  the  specific  gravity  of  the 
uterus  will  make  it  sink  somewhat  lower  in  the  pelvis. 
Subinvolution,  congestion  from  inflammation,  or  retro- 
flexion may  do  this.  In  such  cases,  however,  the  pro- 
lapse never  becomes  extreme,  rarely  extending  beyond  a 
slight  sinking  of  the  uterus. 

In  most  cases  uterine  prolapse  takes  place  slowly. 
Sometimes  many  years  are  necessary  for  the  develop- 
ment of  complete  prolapse.  The  equilibrium  of  the 
pelvic  contents  is  destroyed  by  one  of  the  causes  already 
mentioned.  The  uterus  falls  through  a  certain  distance 
before  the  uterine  ligaments  become  suspensory.  Then, 
however,  its  further  descent  is  impeded. 

If  the  original  cause  continues  to  act,  the  uterine  liga- 
ments become  stretched  and  the  descent  of  the  uterus 
gradually  progresses,  impeded  to  a  varying  degree  also 
by  the  retentive  power  of  the  abdomen  and  the  cellular 
tissue  and  other  pelvic  attachments. 

As  the  uterus  descends,  the  vaginal  walls  attached  at 
the  cervix  are  dragged  down  with  it,  so  that  when  the 
prolapse  becomes  complete  the  vagina  is  turned  inside 
out  (Fig.  67). 

When  the  perineum  has  been  injured  so  that  the  lower 
portion  of  the  vagina  loses  its  support  and  the  equilib- 
rium of  the  pelvic  contents  is  destroyed,   two  distinct 


I02      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

phenomena  occur  :  The  uterus  falls  as  already  described, 
and  at  the  same  time  the  lower  part  of  the  vagina  begins 
to  fall,  so  that  there  appear  a  prolapse  of  the  anterior  vag- 
inal wall,  or  a  cystocele,  and  a  prolapse  of  the  posterior 
wall,  or  a  rectocele.     The  condition  finally  produced  will 


Fig.  67. — Complete  prolapse  of  the  uterus. 


depend  upon  which  prolapse  takes  place  the  more  rap- 
idly— that  of  the  vagina  or  that  of  the  uterus. 

If  the  prolapse  of  the  lower  vagina  progresses  faster 
than  that  of  the  uterus,  then  the  vagina  will  begin  to 
drag  upon  the  cervix,  to  which  it  is  attached,  and  under 
these  circumstances  the  uterus  will  be  subjected  to  two 
downward  forces — intra-abdominal  pressure  from  above, 
and  traction  of  the  vaginal  walls  acting  from  below. 

As  the  traction  is  exerted  upon  the  lower  part  of  the 
cervix,  and  the  body  of  the  uterus  is  sustained  by  the 
uterine  ligaments,  which  resist  the  downward  traction, 
the  isthmus,  or  point  of  junction  of  the  body  and  cervix, 
is  dragged  out  or  stretched,  so  that  in  some  cases  a  very 


PROLAPSE  OF  THE  UTERUS. 


103 


marked  elongation  of  the  supra-vaginal  cervix,  or  the 
part  of  the  cervix  above  the  vaginal  junction,  appears. 
This  elongation  is  sometimes  so  great  that  the  length  of 
the  uterine  cavity  from  external  os  to  fundus  measures 
six  or  eight  inches.  Such  elongation  of  the  cervix  is 
usually  found  to  a  greater  or  less  degree  in  every  case  of 
marked  prolapse  of  the  uterus  caused  by  injury  to  the 


Fig.  68. — Prolapse  of  the  vagina  and  the  vaginal  cervix,  with  great  elongation 
of  the  supra-vaginal  cervix. 


perineum.  Such  a  condition  should  be  described  as  pro- 
lapse of  the  uterus  with  elongation  of  the  supra- vaginal 
cervix  (Fig.  68).  In  many  cases  the  prolapse  of  the  va- 
gina and  the  elongation  of  the  cervix  are  the  most  marked 
features,  the  body  of  the  uterus  falling  but  slightly  below 
its  normal  level.  The  cervix  will  be  found  protruding 
some  distance  from  the  vulva;  the  vagina  will  be  foundl 


I04      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

turned  inside  out;  while  the  fundus  may  be  felt  approx- 
imately at  its  normal  level  in  the  pelvis,  and  the  present- 
ing cervix  and  the  body  of  the  uterus  are  connected  by 
a  round,  cord-like  structure  about  the  size  of  the  little 
finger,  which  is  the  stretched,  attenuated  supra-vaginal 
cervix. 

As  a  result  of  the  traction  upon  the  cervix  the  blood- 
flow  from  the  infra-vaginal  cervix  is  impeded,  and  passive 


Fig.  69. — Prolapse  of  the  vagina  and  cervix,  with  elongation  of  the  supra-vagi- 
nal cervix. 


congestion  results  in  hypertrophy.  This  hypertrophy  is 
increased  by  irritation  of  the  infra-vaginal  cervix  from 
friction  against  the  clothing  and  from  urine,  etc.  In 
such  cases  the  presenting  cervix  becomes  much  larger 
than  normal,  sometimes  measuring  two  or  two  and  a 
half  inches  in  diameter. 

It  will  be  seen  that  very  pronounced  structural  changes 
are  present  in  old  cases  of  prolapse  of  the  uterus.  The 
uterine  ligaments  and  the  pelvic  attachments  become  so 


PROLAPSE  OF  THE  UTERUS. 


105 


stretched  and  atrophied  that  they  can  never  become  func- 
tionally useful  again.  The  normal  shape  and  size  of  the 
uterus  become  very  much  changed  from  elongation  of 
the  supra-vaginal  cervix  and  hypertrophy  of  the  infra- 
vaginal  cervix.  The  vaginal  canal  becomes  patulous 
and  stretched  several  times  bevond  its  normal  dimen- 


FlG.  70. — Prolapse  of  the  vagina  and  the  vaginal  cervix,  with  elongation  of  the 
supra-vaginal  cervix.     Extensive  ulceration. 


sions,  and  the  delicate  mucous  membrane,  from  exposure, 
becomes  tough  and  cutaneous  in  character.  The  large 
protruding  mass  of  uterus  and  inverted  vagina  stretches 
the  genital  outlet  far  beyond  its  normal  dimensions,  and 
the  musciilar  supports  that  may  have  remained  after  the 
original  perineal  injury  undergo  atrophy  from  pressure. 

Accompanying  the  prolapse  of  the  uterus  is  usually 
prolapse  of  the  bladder  and  of  the  anterior  wall  of  the 
rectum,  producing  a  condition  already  described  under 
Cystocele  and  Rectocele. 

Women  who  do  hard  manual  labor  are  those  who  suffer 


lo6       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

with  the  most  marked  forms  of  uterine  prolapse.  The 
form  of  prolapse  accompanied  by  elongation  of  the  supra- 
vaginal cervix  is  usually  characteristic  of  the  hard-work- 
ing woman.  Such  prolapse  of  the  uterus  is  common 
among  the  Western  Indian  women,  who  return  imme- 
diately after  delivery  to  hard  labor  and  horseback-riding. 

Many  cases  of  prolapse  would  be  avoided,  even  though 
there  might  be  serious  perineal  injury,  if  women  remained 
in  bed  a  sufficient  time  after  delivery.  By  rising  too  early 
prolapse  is  favored,  for  a  variety  of  reasons.  The  uterus 
is  large  and  heavy;  the  uterine  ligaments  are  elongated, 
and  the  abdominal  walls  are  weak ;  consequently  the 
retentive  power  of  the  abdomen  is  poor;  the  vagina  is 
flabby  and  much  larger  than  normal ;  the  genital  outlet 
has  not  contracted,  and  the  muscular  and  fascial  supports 
which  may  not  have  been  torn  are  stretched  and  relaxed. 

The  subjective  symptoms  of  prolapse  vary  greatly  and 
are  not  characteristic.  A  woman  in  whom  the  uterus  has 
descended  but  slightly  below  the  normal  level  may  suffer 
so  much  with  backache,  weakness  of  the  legs,  and  a  feel- 
ing of  pelvic  weight,  or  "bearing  down,"  that  her  life 
will  be  rendered  useless;  while,  on  the  other  hand,  a 
woman  with  complete  prolapse  of  the  uterus  may  suffer 
no  inconvenience  except  from  the  presence  of  the  pro- 
truding mass.  In  fact,  the  lesser  degrees  of  prolapse  seem 
to  cause  more  suffering  than  the  extreme  degrees. 

The  first  subjective  symptoms  of  injury  to  the  supports 
of  the  pelvic  floor  that  appear  when  the  woman  leaves 
her  bed  are  those  referable  to  beginning  prolapse  of  the 
uterus.  Backache  is  the  most  common  symptom,  and 
occurs  here  as  in  almost  every  other  disease  of  the  uterus. 
The  pain,  a  dull  ache,  is  situated  in  the  upper  part  of 
the  sacrum.  It  is  increased  by  standing,  by  walking,  or 
by  manual  labor.  It  often  disappears  entirely  when  the 
woman  lies  down  and  the  intra-abdominal  pressure  is 
removed  from  the  uterus.  Headache  situated  in  the 
occipital  region  or  the  vertex  is  also  usually  present,  and 
varies  in  severity  with  the  severity  of  the  backache. 


PROLAPSE  OF  THE  UTERUS.  107 

Pain  extending  down  the  posterior  aspect  of  the  thighs, 
and  a  dragging  feeling  of  loss  of  support  in  the  pelvis, 
may  also  be  present.  The  rectal  and  bladder  symptoms 
occur  later,  when  rectocele  and  cystocele  appear. 

There  is  often  very  marked  general  physical  weakness, 
much  of  which  may  be  referred  directly  to  the  loss  of  the 
muscular  support  of  the  perineum.  Almost  every  effort 
that  the  woman  makes  is  accompanied  by  increase  of 
intra-abdominal  pressure,  and  she  feels  keenly  the  loss 
of  the  accustomed  perineal  support  which  normally 
resists  any  increased  abdominal  pressure.  In  the  sound 
woman  the  perineal  muscles  contract  and  the  vagina  is 
more  tightly  closed  to  meet  the  increased  pressure  inci- 
dent to  a  muscular  effort.  In  the  injured  woman  the 
vagina  is  open  and  the  pressure  is  resisted  by  weak 
vaginal  walls  and  uterine  supports.  She  feels  that  her 
point  of  resistance  is  gone.  The  best  proof  of  the  pro- 
found effect  of  injury  to  the  perineum  upon  the  general 
strength  of  a  woman  is  given  by  the  operation  of  peri- 
neorrhaphy. The  repair  of  this  apparently  slight  lesion 
restores  the  woman  to  her  former  strength. 

The  diagnosis  of  prolapse  of  the  uterus  is  readily 
made  by  examination.  In  the  extreme  cases  the  cervix 
and  the  greater  part  of  the  body  of  the  uterus  are  found 
outside  the  vulva.  In  less  marked  cases  the  cervix 
is  seen  presenting  at  the  vaginal  orifice  as  soon  as  the 
labia  are  separated.  In  other  cases  the  cervix  is  felt  by 
the  vaginal  finger  resting  on  the  pelvic  floor.  It  should 
be  remembered  that  every  case  of  prolapse  is  greater 
when  the  woman  is  standing  than  when  she  is  being 
examined  upon  her  back.  Sometimes  the  cervix  will 
present  at  the  vulva,  where  it  may  be  felt  when  the 
woman  is  erect;  but  when  she  lies  down  and  intra- 
abdominal pressure  is  removed,  it  retreats  beyond  inspec- 
tion except  through  the  speculum.  In  order  to  determine 
the  full  extent  of  prolapse,  therefore,  when  the  woman  is 
examined  on  her  back  she  should  be  directed  to  strain  or 
bear  down,  when  much  more  marked  descent  of  the 
uterus  and  vaginal  walls  will  become  apparent. 


iO«      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  lesser  degrees  of  prolapse,  in  which  the  cervix  has 
not  yet  fallen  enough  to  rest  on  the  pelvic  floor,  are  more 
difficult  to  recognize  by  bimanual  examination.  It  will 
be  found  that  the  upward  range  of  motion  of  the  uterus 
is  greater  than  normal,  and  vaginal  examination  when 
the  woman  is  erect  will  make  the  condition  more 
apparent. 

Bxtreme  prolapse  of  the  uterus,  in  which  we  find  pro- 
truding from  the  vulva  a  pear-shaped  tumor  at  the  apex 
of  which  is  the  opening  of  the  cervical  canal,  should  not 
be  mistaken  for  any  other  condition.  Inversion  of  the 
uterus  and  a  uterine  polyp  resemble  it  only  in  shape,  and 
in  no  other  particular.  If  there  is  any  doubt,  it  may  be 
dispelled  by  placing  the  woman  in  the  knee-chest  posi- 
tion, when  the  prolapse  may  readily  be  reduced  and  the 
normal  anatomical  relations  restored. 

Treatment. — As  prolapse  of  the  uterus  is  usually 
caused  by  defective  uterine  supports,  treatment  should 
be  directed  in  the  first  place  to  the  restoration  of  the 
perineum. 

In  slight  cases  of  prolapse  that  are  seen  early,  restora- 
tion of  the  perineum  by  Emmet's  operation  is  sufficient 
for  cure. 

In  cases  of  long  duration,  however,  we  have  to  deal 
with  a  variety  of  secondary  conditions.  These  are  as 
follows  :  Hypertrophy  of  the  uterus  from  subinvolution 
or  congestion;  elongation  of  the  cervix  ;  hypertrophy  of 
the  cervix;  elongation  of  the  uterine  ligaments;  stretch- 
ing of  the  vagina;  stretching  of  the  genital  outlet;  and 
atrophy  of  all  the  structures  of  the  perineum  from  pres- 
sure. The  atrophic  changes  give  the  most  difficulty. 
The  prognosis,  therefore,  depends  upon  the  duration  of 
the  case. 

In  cases  of  prolapse  in  which  the  cervix  has  reached  or 
has  passed  the  ostium  vaginae,  rest  in  bed  in  the  recum- 
bent position  should  always  be  prescribed  for  two  to  four 
weeks  before  any  operative  procedure.  The  woman 
should  be  placed  in  the  knee-chest  position  and  the  pro- 
lapse of  the  uterus  and  vagina  should  be  reduced.     Re- 


PROLAPSE  OF  THE  UTERUS.  109 

duction  of  this  kind  should  be  practised  as  often  as  the 
prolapse  returns — as,  for  instance,  after  straining  at  stool. 
It  may  be  performed  by  the  woman  herself  or  by  the 
nurse.  It  is  well  for  the  woman  to  asssume  the  knee- 
chest  position  three  or  four  times  a  day,  for  five  to 
fifteen  minutes  at  a  time.  One  or  two  hot  vasfinal 
douches  of  a  gallon  of  i  :  4000  bichloride  solution 
should  be  administered  daily.  The  intestinal  contents 
should  be  kept  soft  by  laxatives.  As  a  result  of  such 
preparatory  treatment  the  uterus  will  diminish  very  much 
in  size,  and  the  vagina  and  the  vaginal  outlet  will  con- 
tract, so  that  at  the  time  of  operating  the  amount  of  tissue 
to  be  removed  may  be  more  accurately  determined.  The 
diminution  in  the  length  of  an  elongated  cervix  as  a 
result  of  rest  is  most  striking,  and  demonstrates  the  truth 
of  the  explanation  of  the  etiology  of  this  condition  that 
has  already  been  given.  A  uterine  canal  that  measures 
five  or  six  inches  in  length  may  be  reduced  to  three  or 
four  inches  after  traction  on  the  cervix  has  been  removed 
by  rest  in  bed. 

Ulceration  of  the  cervix,  which  is  often  present  as  a 
result  of  friction  from  exposure,  readily  yields  to  this 
treatment  of  rest  and  douches. 

From  the  considerations  already  referred  to  it  will 
be  seen  that  the  operative  treatment  of  any  case  of  uter- 
ine prolapse  varies  according  to  the  special  conditions 
present. 

Perineorrhaphy  is  always  necessary.  Emmet's  opera- 
tion is  usually  the  best  one.  The  denudation  in  the 
lateral  vaginal  sulci  should  be  extended  well  up  the  pos- 
terior vaginal  wall,  in  order  to  diminish  the  caliber  of 
the  overstretched  vagina.  One  of  the  operations  already 
described  should  also  be  performed  for  the  cure  of  the 
cystocele  and  to  diminish  the  area  of  the  anterior  vag- 
inal wall.  The  best  of  these  operations  is  that  shown  in 
Fig.  60,  After  all  plastic  operations  for  the  cure  of 
prolapse  the  woman  should  be  kept  in  bed  for  three  or 
four  weeks — the  longer  the  better — so  that  the  perineal 


no      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

and  vaginal  structures  and  the  ligaments  of  the  uterus 
may  contract  and  regain  strength. 

In  some  cases  of  long  standing  it  is  impossible,  by 
operation,  to  restore  the  integrity  of  the  pelvic  floor,  and 
to  restore  the  shape,  size,  and  direction  of  the  vaginal 
canal  so  that  the  normal  equilibrium  of  the  pelvic  con- 
tents will  be  re-established.  In  such  cases  operators  have 
attempted  to  build  a  direct  mechanical  support  for  the 
uterus. 

Le  Fort's  operation  is  an  ingenious  method  of  attain- 
ing this  object.  The  uterus  should  be  replaced,  and  a 
longitudinal  strip  of  tissue,  about  one-half  to  one  inch  in 
breadth  and  two  to  two  and  a  half  inches  in  length, 
should  be  denuded  on  the  anterior  vaginal  wall,  extend- 
ing from  a  point  near  the  vulva,  where  the  two  vaginal 
walls  are  in  contact  when  the  uterus  is  in  place,  up  to- 
ward the  cervix.  A  similar  strip  should  be  denuded  on 
the  posterior  wall.  These  two  denuded  areas  should  be 
brought  into  apposition  by  interrupted  sutures  passed 
transversely.     Perineorrhaphy  should  also  be  performed. 

In  those  cases  in  which  the  vagina;  and  the  vaginal 
outlet  have  become  very  much  stretched  by  the  protrud- 
ing mass  of  prolapsed  structures,  Emmet's  operation 
seems  to  be  insufficient.  In  such  cases  the  following 
operation  is  useful.  This  consists  in  denuding  a  tri- 
angular area  on  the  posterior  vaginal  wall  (Fig.  ^'j)., 
the  apex  of  the  denudation  being  immediately  below  the 
cervix,  and  the  base  at  the  ostium  vaginae.  The  denuda- 
tion should  extend  well  on  to  the  lateral  vaginal  walls. 
The  denuded  area  is  then  closed  by  sutures  passed  trans- 
versely. 

Judgment,  derived  from  experience,  is  necessary  in 
choosing  and  performing  the  various  plastic  operations 
for  prolapse  of  the  uterus. 

In  every  case  of  prolapse  a  certain  degree  of  retrover- 
sion of  the  uterus  is  present.  In  fact,  the  uterus  could 
not  escape  from  the  vagina  unless  the  fundus  were  turned 
somewhat  backward.     The  operation  of  ventro-fixation 


PROLAPSE  OF  THE  UTERUS. 


Ill 


of  the  uterus  is  therefore  a  useful  adjunct  in  some  cases 
of  uterine  prolapse.  The  operation  is  not  intended  to 
furnish  a  mechanical  support  to  the  uterus,  but  only  to 
keep  it  in  a  position  of  anteversion,  so  that  it  will  less 
readily  escape  through  the  vaginal  canal.  The  plastic 
operations  and  the  ventro-suspension  may  all  be  done  at 
the  same  sitting. 

Whenever  there  is  hypertrophy  of  the  infra-vaginal 
cervix,  this  structure  should  be  amputated  in  addition  to 
the  other  operations. 


Fig.  71. — Prolapse  of  the  vagina  and  of  the  infra-vaginal  cervix.  The 
sound  shovi?ed  the  internal  uterine  length  to  be  5)^  inches.  An  erosion  ap- 
pears on  the  posterior  margin  of  the  os  uteri. 

In  those  very  rare  cases  of  incurable  prolapse  that 
have  resisted  all  conservative  treatment  the  operation  for 
the  removal  of  the  uterus  must  be  considered. 

This  operation,  however,  should  not  be  proposed  hasti- 
ly. The  surgeon  should  not  become  discouraged  by  one 
or  even  two  failures  of  the  more  conservative  methods  of 
treatment.     Though  the  first  plastic  operation  may  fail 


112       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

A  B 


Fig.  72. — Amputation  of  the  hypertrophied  cervix:  A.  The  cervix  has  been  split  laterally. 
B.  The  posterior  lip  is  being  amputated. 


Fig.  73. — The  posterior  lip  has  been  amputated. 


PROLAPSE  OF  THE  UTERUS. 

A  B 


1^3 


Fig.  74. — A.  Both  lips  have  been  amputated  and  the  sutures  have  been  introduced.     B.  The 
sutures  have  been  secured  by  the  perforated  shot. 


Fig.  75,— /I.    I  he  anterior  vaginal  wall  is  pushed  bacl<ward  by  the  staff,  while  on  each  side 
01  the  median  line  portions  of  mucous  membrane  are  grasped  by  tenacula  and  brought  to- 
gether in  order  to  determine  the  position  of  the  strips  to  be  denuded.     B.  Denudation  on  the 
anterior  vaginal  wall  (Sims   operation) 
8 


114       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

A  B 


Fig.  76. — A.  The  sutures  have  been  introduced.  The  prolapsed  vagina  and  cervix  have 
been  reduced.  The  cystocele  is  pushed  upward  by  the  staff,  so  that  the  denuded  strips  may 
be  brought  into  apposition.  B.  The  sutures  are  secured.  The  cystocele  has  disappeared. 
The  area  of  the  anterior  vagina]  wall  and  the  caliber  of  the  vagina  have  been  much  di- 
minished. 

A  B 


Fig.  77. — A.  A  point  on  the  median  line  of  the  posterior  vaginal  wall,  about  an  inch  below 
the  cervix,  has  been  seized  by  the  tenaculum.  This  marks  the  apex  of  a  triangle  the  base 
of  which  is  at  the  ostium  vaginae  and  the  sides  of  which  are  on  the  lateral  vaginal  walls.  B. 
The  triangle  has  been  denuded.     The  sutures  have  been  introduced. 


PROLAPSE  OF  THE  UTERUS. 


115 


to  retain  the  uterus  inside  the  body,  yet  something  is  al- 
ways accomplished  by  it,  and  when  supplemented  by  a 
second  or  a  third  operation,  cure  will  often  result. 

The  operative  procedures  required  in  a  case  of  pro- 
lapse of  the  vagina  and  of  the  infra-vaginal  cervix,  with 
hypertrophy  of  the  infra- vaginal  cervix  and  elongation 
of  the  supra- vaginal  cervix,  are  illustrated  in  Figs.  71-78. 


Fig.  78. — The  sutures  in  the  posterior  vaginal  wall  have  been  secured.  The 
caliber  of  the  vagina  has  been  very  much  diminished.  A  strong  sling  or  band 
of  tissue  has  been  formed  immediately  above  the  ostium  vaginas,  which  sup- 
ports the  lower  portion  of  the  posterior  vaginal  wall.  The  operation  is  com- 
pleted. 


The  condition  represented  in  Fig.  71  is  that  which  is 
commonly  spoken  of  as  "prolapse  of  the  uterus."  It  is 
the  usual  form  of  prolapse.  It  may  be  cured  in  the  very 
great  majority  of  cases  by  the  operations  which  are  here 
depicted. 

A  great  number  of  mechanical  devices  have  been  in- 
troduced for  the  relief  of  prolapse  of  the  uterus.  Every 
vaginal  pessary  has  been  used  for  this  condition.     None 


Ii6       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


of  these  implements  cure  the  disease.  All  of  them,  if 
used  continuously,  produce  ulceration  of  the  vagina  and 
of  the  cervix  from  pressure,  and  must  be  abandoned  until 
such  lesions  heal.  In  those  cases  of  prolapse  in  which 
pessaries  remain  in  the  vagina  and  support  the  uterus, 
without  producing  ulceration,  operation  would  effect  a 
cure. 

Mechanical  supports  of  this  kind  are  only  indicated  in 
women  in  whom  operation  is  contraindicated  on  account 

of  old  age  or  for  some  other  rea- 
son. Perhaps  the  best  instru- 
ment for  supporting  the  uterus 
in  such  cases  is  Braun's  colpeu- 
rynter  (Fig.  79).  The  uterus 
should  be  reduced,  and  the  col- 
peurynter,  well  greased  and  con- 
taining about  an  ounce  of  water, 
should  be  introduced  in  the  vagina  and  then  distended 
with  air.  This  instrument  takes  its  support  evenly  from 
all  parts  of  the  vaginal  outlet,  and  is  therefore  less  apt  to 
produce  ulceration  from  pressure  than  the  various  pessa- 
ries.    It  should  be  removed  at  night. 


Fig.  79. — Braun's  colpeurynter. 


CHAPTER   X. 
ANTEFLEXION  OF  THE  UTERUS. 

As  has  already  been  said,  the  uterus  normally  lies  with 
its  anterior  surface  in  contact  with  the  posterior  surface 
of  the  bladder,  and  with  its  long  axis  approximately  per- 
pendicular to  the  long  axis  of  the  vagina.  The  forward 
inclination  of  the  uterus  varies  with  the  degree  of  dis- 
tention of  the  bladder;  it  is  greatest  when  the  bladder  is 
collapsed. 

In  the  normal  woman  the  long  axis  of  the  body  of  the 
uterus  is  inclined  forward  at  an  obtuse  angle  with  the 
long  axis  of  the  cervix.  In  other  words,  the  uterus  is 
normally  anteflexed.  This  angle  is  subject  to  rather  wide 
variations  within  the  limits  of  health.  It  is  greater  in 
the  multiparous  than  in  the  nuUiparous  woman.  It  varies 
with  the  distention  of  the  bladder,  the  position  of  the 
woman,  and  the  intensity  of  intra-abdominal  pressure. 
The  axis  of  the  uterus  when  removed  from  the  body  is 
usually  straight.  The  anteflexion  found  in  the  organ 
when  in  situ  in  the  living  woman  rarely  persists.  The 
normal  or  physiological  anteflexion  is  maintained  during 
life  by  the  utero-sacral  ligaments,  which  hold  the  cervix 
back,  and  the  intra-abdominal  pressure,  which,  acting 
upon  the  posterior  aspect  of  the  fundus,  pushes  the  body 
of  the  uterus  forward. 

In  the  fetus  and  in  early  infancy  the  cervix  is  rela- 
tively much  more  developed  than  the  body  of  the  uterus, 
and  there  is  a  very  marked  angle  of  flexion  between 
them. 

Anteflexion  of  the  uterus  becomes  pathological  when 

117 


11^ 


A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


the  bend  in  the  cervical  canal  is  sufficient  to  impede  the 
escape  of  menstrual  blood  or  other  uterine  discharges. 

Obstruction  of  this  kind  depends  upon  two  factors — 
the  degree  of  the  flexion,  and  the  rigidity  of  the  uterus, 
which  diminishes  the  mobility  that  normally  exists  at 
the  angle  of  flexion. 

No  matter  how  sharp  the  angle  of  flexion,  it  should 
not  be  considered  a  pathological  condition  unless  obstruc- 
tion in  the  cervical  canal  is  present — unless  the  woman 
presents  the  symptoms  of  dysmenorrhea  and  sterility. 

Three  varieties  of  anteflexion  have  been  described : 

I.  Corporeal  anteflexion^  in  which  the  cervix  has  the 
normal  backward  direction,  and  the  body  of  the  uterus  is 
bent  forward  upon  it  (Fig.  80). 


Fig.  80. — Corporeal  anteflexion. 


II.  Cervical  anteflexion^  in  which  the  axis  of  the  body 
of  the  uterus  is  inclined  forward  to  the  normal  degree, 
and  the  cervix  is  bent  forward  upon  it  (Fig.  81). 

III.  Cervico-corporeal  anteflexion.^  when  the  cervix  and 
body  of  the  uterus  are  both  bent  forward  upon  each  other 
(Fig.  82). 

Anteflexion  of  the  uterus  is  a  disease  of  single  and 
sterile  married  women.     It  is  very  rarely  found  in  women 


ANTEFLEXION  OF  THE  UTERUS. 


119 


who  have  borne  children.     The  disease  is  congenital  or 
is  caused  by  imperfect  development  during  childhood. 


Fig.  81. — Cervical  anteflexion. 


The   fetal    condition  of   a  large  cervix  and  a  small, 
sharply-flexed  body  may  persist.     The  posterior  wall  of 


Fig.  82. — Cervico-corporeal  anteflexion. 

the   uterus  may  develop  while  the   development  of  the 
anterior  wall  is  arrested,  and  thus  the  uterus  would  be 


I20      A   TEXT- BOOK  OF  DISEASES  OF  WOMEN. 

flexed  forward.  A  mark  of  such  arrest  of  development 
is  sometimes  seen  in  the  atrophied  or  undeveloped  ante- 
rior lip  of  the  cervix.  An|;eflexion  is  usually  accom- 
panied by  a  small,  undeveloped  condition  of  the  whole  of 
the  uterus,  and  often  by  poorly  developed  vagina,  tubes, 
and  ovaries. 

It  is  probable  that  improper  dress  and  hygiene  during 
the  period  of  puberty  have  much  to  do  with  the  develop- 
ment of  anteflexion.  The  early  menstrual  history  some- 
times points  to  poor  development  of  the  sexual  organs. 
The  menses  often  make  their  appearance  much  later  than 
usual — sometimes  when  a  girl  is  nineteen  or  twenty  years 
of  age — and  when  established,  the  function  is  often 
irregular,   the  bleeding  recurring  at  long  intervals. 

The  most  prominent  symptom  of  anteflexion  of  the 
uterus  is  dysmenorrhea,  or  painful  menstruation.  The 
dysmenorrhea  is  characteristic:  violent  pains  in  the  center 
of  the  lower  abdomen,  extending  down  the  thighs,  occur 
for  several  hours  before  the  bleeding  begins.  In  the  later 
years  of  the  disease  the  pain  extends  to  the  whole  of  the 
pelvis  and  the  back.  The  pain  is  caused,  in  all  prob- 
ability, by  the  accumulation  of  blood  behind  the  obstruc- 
tion in  the  cervical  canal.  When  the  blood  begins  to 
escape  freely,  the  pain  is  relieved,  and  may  be  absent 
during  the  remainder  of  the  menstrual  period.  The 
blood  is  often  clotted  during  the  first  part  of  the  flow. 
Nausea  and  vomiting  may  be  present  during  the  height 
of  the  pain. 

The  menstrual  period  may  be  followed  by  several  days 
■of  great  physical  weakness  and  debility. 

Unless  relieved  by  pregnancy  or  by  proper  treatment, 
the  anteflexion  will  persist  during  the  menstrual  life  of 
the  woman.  The  suffering  increases  with  time.  Endo- 
metritis, salpingitis,  and  ovaritis  follow  old  cases  of  ante- 
flexion. 

Sterility  usually  accompanies  well-marked  anteflexion. 
This  may  be  due  to  the  altered  direction  of  the  cervix  in 
■case  of   cervical  anteflexion,    to  the  obstruction  in  the 


ANTEFLEXION  OF  THE  UTERUS.  121 

cervical  canal  that  interferes  with  the  ingress  of  sperma- 
tozoa, to  the  generally  undeveloped  condition  of  the 
genital  organs,  or  to  the  inflammation  of  the  mucous 
membrane  of  the  cervix  and  the  body  of  the  uterus. 

The  diagnosis  of  anteflexion  is  easily  made.  The  cha- 
racter, position,  and  time  of  onset  of  the  pain  indicate 
some  obstruction  to  the  escape  of  menstrual  blood.  Vag- 
inal examination  reveals  the  sharp  angle  of  flexion  at  the 
junction  of  the  body  and  neck  of  the  uterus. 

Treatment. — If  in  a  case  of  anteflexion  pregnancy 
does  occur  and  runs  a  normal  course^  the  disease  will  be 
cured.  After  labor  the  uterus  does  not  return  to  the 
infantile  shape  and  size.  The  stimulus  of  pregnancy 
brings  about  full  permanent  development  of  that  organ. 
Miscarriage,  however,  is  very  apt  to  occur  during  the 
early  months  of  pregnancy,  especially  in  cases  of  long 
standing. 

Various  methods  of  treatment  have  been  introduced 
for  the  cure  of  anteflexion.  The  object  of  all  these 
methods  is  the  straightening  and  enlargement  of  the 
cervical  canal.  Slow  dilatation  by  graduated  bougies 
has  been  successfully  employed.  Gradual  straightening 
of  the  canal  by  the  introduction  of  the  uterine  sound 
with  increasing  angle  of  flexion  will  also  cure  some 
cases,  if  seen  early. 

The  use  of  the  stem  pessary  (Fig.  83), 
which  is  worn  continuously  in  the  cervi- 
cal canal,  is  dangerous  and  should  not  be 
practised. 

The  best  method  of  treatment  consists 
in  rapid  forcible  dilatation  with  the  ute- 
rine dilator.  Various  instruments  have 
been  made  for  this  purpose.  The  prin- 
ciple of  all  is  the  same.      Two  blades  are      ^^^-  ^3-— Stem 

•     .        11-  -I  •       -I  pessary. 

mtroduced,    in    contact,    m    the    cervical 
canal,   and    are    then   separated.      Two  of   these  instru- 
ments should  be  on  hand — a  small  and  a  lar^e  dilator. 
The  Goodell  dilator  (Figs.  84,  85)  is  so  made  that  the 


122       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

blades  open  parallel  with  one  another,  so  that  the  whole 
of  the  cervical  canal  is  uniformly  stretched. 

The  best  time  to  perform  forcible  dilatation  is  about 
one  week  after  a  menstrual  period.  The  woman  should 
be  etherized  and  placed  in  the  dorso-sacral  position.  The 
vagina  should  be  sterilized.    All  aseptic  precautions  which 


Fig.  84. — Goodell's  small  uterine       Fig.  85. — Goodell's  large  uterine 
dilator.  dilator. 

one  would  follow  in  any  gynecological  operation  should 
be  observed  here.  There  is  always  danger  of  producing 
septic  inflammation  of  the  endometrium.  The  cervix 
should  be  exposed  through  the  Sims  speculum,  and  the 


ANTEFLEXION  OF  THE  UTERUS.  123 

anterior  lip  should  be  seized  with  the  double  tenaculum. 
Downward  traction  on  the  cervix  straightens  the  cervical 
canal  and  renders  easier  the  introduction  of  the  dilator. 
The  smaller  dilator  should  first  be  introduced.     No  force 
should  be  used  in  passing  it  through  the  cervical  canal. 
If  an  obstruction  which  cannot  be  gently  overcome  is 
met,  the  dilator  should  be  introduced  as  far  as  the  ob- 
struction   and    the    blades    should    then    be    separated. 
Slight  dilatation  of  this  kind  below  the  angle  of  flex- 
ion will  usually  enable  the  operator  to  pass  the  instru- 
ment through  the  cervical  canal  at  a  subsequent  attempt. 
After  the  smaller  instrument  has  been  introduced  to  the 
full  extent  the  blades  should  be  gradually  separated,  for 
a  half  inch  or  more,  until  the  canal  becomes  large  and 
straight  enough  to  admit  the  large  instrument.    It  should 
always  be  remembered  that  no  force  should  be  used  in 
the  introduction  of  either  instrument.    After  introduction 
the  blades  of  the  large  dilator  should  be  slowly  separated. 
On  the  handles  of  the  Goodell  instrument  is  a  graduated 
scale  showing  the  extent  of  the  dilatation.     In  no  case 
should  the  dilatation  be  carried  beyond  one  and  a  half 
inches.     In  women  in  whom  the  cervix  and  uterus  are 
small  an  inch  of  dilatation  is  sufScient.     The  maximum 
dilatation  should  be  reached  slowly  and  gradually.    Lace- 
ration of  the  cervix  or  of  the  margin  of  the  external  os 
should  be  avoided.     Sometimes  ten  or  fifteen  minutes  are 
required  before  full  dilatation   is  attained.     When  this 
point  is  reached  the  handles  should  be  held  in  place  by 
the  screw,  and  the   instrument  should  be  kept  in  the 
uterus  for  ten  or  fifteen  minutes  longer.      The  longer 
the  dilatation,  the  more  permanent  will  be  the  result. 

After  the  instrument  is  withdrawn  the  cervical  canal 
and  the  vagina  should  be  washed  out  with  a  i  :  2000  solu- 
tion of  bichloride  of  mercury,  and  a  light  gauze  pack 
should  be  introduced  into  the  vagina.  The  pack  should 
be  removed  at  the  end  of  forty-eight  hours,  and  a  daily 
douche  of  i  :  4000  bichloride  solution  should  be  admin- 
istered for  the  following  week.     The  patient  should  re- 


124      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

main  in  bed  for  two  weeks,  or  longer  if  there  is  any  pelvic 
pain.  Pain,  however,  does  not  follow  this  operation  if 
we  avoid  operating  upon  those  cases  in  which  there  is 
inflammatory  disease  of  the  tubes  and  ovaries.  The  too 
early  resumption  of  the  erect  position  may  cause  the  fail- 
ure of  the  operation.  The  abdominal  pressure  exerted 
upon  the  fundus  uteri,  before  the  organ  has  become 
fixed  in  its  altered  shape,  may  bring  about  a  recurrence 
of  the  anteflexion.  In  case  the  external  os  be  very  small 
— too  small  to  admit  the  dilators — it  may  be  incised  by 
small  crucial  incisions  or  reamed  out  with  the  closed 
blades  of  the  scissors. 

Dilatation  of  this  kind  usually  produces  a  permanent 
broadening  and  shortening  of  the  cervix.  The  cervical 
canal  is  rendered  straighter  and  larger. 

The  good  effects  of  the  operation  are  not  always  appa- 
rent at  the  menstrual  period  immediately  following  the 
operation,  because  the  results  of  the  traumatism  to  the 
mucous  membrane  and  the  structures  of  the  cervix  are 
still  present.  At  the  periods  after  this,  however,  the 
dysmenorrhea  is  absent  or  is  very  much  relieved.  The 
benefit  usually  derived  from  this  operation  is  a  strong 
proof  of  the  truth  of  the  obstructive  theory  of  the  dys- 
menorrhea. If,  after  dilatation,  conception  takes  place, 
the  woman  may  look  forward  to  perfect  cure.  In  some 
cases  the  dilatation  does  not  seem  to  be  sufficient  to  pro- 
duce a  permanent  open  condition  of  the  cervical  canal, 
and  the  signs  of  obstruction  (dysmenorrhea)  return.  In 
such  a  case  the  dilatation  should  be  repeated.  The  more 
thoroughly  the  dilatation  is  performed  the  first  time  the 
less  often  will  the  second  operation  be  necessary. 


CHAPTER   XI. 

RETROFLEXION  AND  RETROVERSION  OF  THE 
UTERUS. 

Retroversion  of  the  uterus  means  a  turning  back  or 
a  backward  rotation  of  that  organ.  The  shape  of  the 
uterus  may  not  be  altered.  The  fundus,  instead  of  lying 
forward  upon  the  bladder,  is  directed  backward,  and 
sometimes  lies  in  the  hollow  of  the  sacrum  (Fig.  86). 


Fig.  86. — Retroversion  of  the  uterus. 

Retroflexion  means  a  bending  backward  of  the  uter- 
ine axis.  The  axis  of  the  body  of  the  uterus  is  normally 
inclined  forward  at  an  obtuse  angle  with  the  axis  of  the 
cervix.     When  the  axis  of  the  body  of  the  uterus  is  in- 

125 


126      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

clined  backward  at  an  angle  with  the  axis  of  the  cervix, 
retroflexion  exists.  Retroflexion  may  vary  in  extent  from 
an  angle  very  little  less  than  i8o  degrees  to  an  angle  con- 
siderably less  than  90  degrees  (Fig.  87). 


Fig.  87. — Retroflexion  of  the  uterus 


Retroflexion  and  retroversion  usually  coexist.  The 
conditions  are  due  to  similar  causes.  They  may  origi- 
nate simultaneously,  or  one  condition,  occurring  pri- 
marily, may  induce  the  other. 

An  infinite  number  of  degrees  of  retroversion  may 
exist.  For  convenience  of  clinical  description  three 
degrees  have  been  described.  In  the  first  degree  the 
fundus  uteri  is  directed  upward  approximately  toward 
the  promontory  of  the  sacrum.  In  the  second  degree 
the  uterus  lies  transversely  across  the  pelvis,  the  fundus 
and  the  cervix  being  at  about  the  same  level.  In  the 
third  degree  the  retroversion  is  extreme,  and  the  fundus 
lies  below  the  level  of  the  cervix  (Fig.  88). 

Retroversion  of  the  uterus  is  progressive.  It  usually 
proceeds  from  bad  to  worse.     As  soon  as  the  downward 


RETROFLEXION  AND  RETROVERSION. 


127 


abdominal  pressure  begins  to  act  upon  the  anterior  face 
of  the  uterus  there  is  a  continuous  force  increasing  the 
retroversion. 

There  are  many  causes  of  retroversion  and  retroflexion. 


Fig.  88. — Diagram  of  the  degrees  of  retroversion  of  the  uterus. 

The  disease  may  be  congenital.  Extreme  retroflexion 
has  been  found  in  the  uterus  of  the  new-born  infant. 
Congenital  retroversion  and  retroflexion  may  be  due  to 
imperfect  development,  and  resulting  imperfect  invagina- 
tion of  the  cervix.  The  condition  may  also  be  caused  by 
arrest  of  development  of  the  posterior  wall  of  the  uterus; 
the  anterior  wall  thus  outgrowing  the  posterior. 

Many  cases  of  retroversion  undoubtedly  originate  dur- 
ing girlhood  as  a  result  of  falls,  blows,  distortion  of  the 
body,  or  sudden  efforts  at  lifting.  The  origin  of  the 
symptoms  may  be  traced  in  many  cases  directly  to  some 
such  cause. 

The  uterus  may  be  considered  to  be  balanced  upon  an 
axis  running  transversely.  Anything  that  turns  the 
uterus  backward,  so  that  the  intra-abdominal  pressure 
may  act  upon  the  anterior  wall,   will  produce  retrover- 


128       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

sion.  It  is  probable  that  an  over-distended  bladder  occa- 
sionally acts  as  a  cause  of  retroversion. 

Retroversion  is  not  at  all  rare  in  single  women.  It 
is  very  often  discovered  soon  after  the  establishment  of 
the  menstrual  function,  the  symptoms  of  the  retrover- 
sion, which,  probably  occurred  during  girlhood,  first 
appearing  at  this  time.  Retroflexion,  on  the  other 
hand,  except  to  the  slight  extent  caused  by  the  retro- 
version,  is  unusual  in  single  women. 

Parturition  is  probably  the  most  frequent  cause  of 
retroversion  and  retroflexion  of  the  uterus.  If  the  woman 
leaves  her  bed  or  goes  to  work  too  soon  after  miscarriage 
or  labor,  many  conditions  are  present  that  favor  retrodis- 
placement  of  the  uterus.  The  uterus  is  larger  and  heavier 
than  normal,  as  a  result  of  imperfect  involution:  the 
uterine  ligaments  are  lax;  the  vagina  and  the  vaginal 
orifice  are  relaxed,  and  the  support  of  the  pelvic  floor  is 
consequently  deficient;  the  abdominal  walls  are  relaxed 
and  the  retentive  power  of  the  abdomen  is  diminished. 
It  will  be  remembered  that  these  are  the  causes  that  favor 
prolapse  of  the  uterus;  in  fact,  a  slight  degree  of  uterine 
prolapse  usually  accompanies  such  cases  of  retrodisplace- 
ment.  A  certain  amount  of  retroversion  must  always 
exist  before  the  uterus  can  pass  along  the  vagina.  It 
must  turn  backward,  so  that  its  axis  becomes  parallel  to 
the  axis  of  the  vagina. 

Retroflexion  occurring  after  miscarriage  or  labor  is 
sometimes  the  result  of  unequal  involution  in  the  uter- 
ine walls.  If  the  involution  takes  place  more  completely 
in  the  posterior  than  in  the  anterior  wall  of  the  uterus,  a 
bending  back,  or  a  retroflexion,  will  occur.  Such  inequal- 
ity of  involution  may  result  from  inflammation  about  the 
site  of  the  placenta. 

Retroflexion  is  a  disease  of  the  parous  woman,  as  ante- 
flexion is  a  disease  of  the  single  and  the  sterile  woman. 

Retroversion  may  be  a  direct  result  of  laceration  of 
the  perineum.  When  the  pelvic  floor  is  destroyed  and 
the  posterior  vaginal  wall  begins  to  prolapse,   it  drags 


RE  TROFLEXION  AND  RE  TRO  VERSION.         1 29 

upon  the  posterior  wall  of  the  cervix,  and  may  in  this 
way  turn  the  uterus  backward. 

Retroversion  also  results  from  traction  of  inflammatory 
adhesions  in  the  pelvis.  Cases  of  chronic  inflammation 
of  the  Fallopian  tubes  accompanied  by  inflammation  of 
the  pelvic  peritoneum  present  adhesions  between  the  pos- 
terior wall  of  the  uterus  and  the  hollow  of  the  sacrum ; 
these  adhesions  drag  the  uterus  backward  (Fig.  89). 


Fig.  89. — Retroversion  of  the  uterus,  with  adhesions  binding  it  to  the  anterior 
wall  of  the  rectum  and  the  hollow  of  the  sacrum. 

In  cases  of  retroversion  and  retroflexion  of  the  uterus 
serious  derangement  of  the  circulation  results.  A  state 
of  passive  congestion  follows  interference  with  the  ven- 
ous supply.  This  congestion  produces  some  enlarge- 
ment of  the  uterus  and  chronic  congestion  or  inflam- 
mation of  the  endometrium.  Consequently,  in  all  old 
cases  of  retrodisplacement  endometritis  is  an  accom- 
paniment. 


130       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Retroversion  of  the  uterus  causes  traction  on  the  ves- 
ico-uterine  connection,  and  the  neck  of  the  bladder  is 
dragged  upon ;  for  this  reason  irritability  of  the  bladder, 
characterized  by  frequent  and  perhaps  painful  micturi- 
tion, is  often  present  in  cases  of  retroversion.  It  is  not 
uncommon  to  see  women  who  have  received  treatment 
directed  to  the  bladder  for  conditions  of  this  kind  that 
disappear  immediately  when  the  uterus  is  restored  to  the 
normal  position. 

The  pressure  of  the  displaced  fundus  upon  the  rectum 
may  also  give  trouble.  Women  in  this  condition  often 
complain  of  a  feeling  of  obstruction  in  the  rectum. 
Pressure  upon  the  hemorrhoidal  veins  results  in  hem- 
orrhoids. 

There  usually  accompanies  retroversions  of  the  uterus 
a  backward  and  downward  displacement  of  the  ovaries — 
in  other  words,  a  prolapse  of  the  ovaries. 

The  symptoms  of  retrodisplacement  are  numerous, 
and  may  be  referred  directly  to  the  altered  position  of 
the  uterus  and  the  accompanying  conditions.  There  are 
backache  situated  in  the  upper  part  of  the  sacrum,  and 
headache  situated  on  the  top  of  the  head  or  in  the  occi- 
put. These  may  be  considered  the  two  constant  symp- 
toms. There  is  a  feeling  of  weight  and  dragging  in  the 
pelvis,  extending  down  the  thighs.  Physical  weakness, 
or  inability  to  walk  or  stand  for  more  than  a  short  time, 
is  often  very  marked,  and  seems  to  be  out  of  all  propor- 
tion to  the  lesion  of  the  uterus.  The  manner  in  which 
such  weakness  of  the  legs  is  produced  is  not  very  evi- 
dent. That  it  is  caused  directly  by  the  displacement 
of  the  uterus,  however,  is  proved  by  the  fact  that  it  dis- 
appears as  soon  as  the  uterus  is  restored  to  its  normal 
position. 

The  accompanying  prolapse  of  the  ovaries  produces 
symptoms  referable  to  these  organs,  the  chief  symptom 
being  pain  in  each  ovarian  region. 

The  irritability  of  the  bladder  has  already  been  spoken 
of.     Menorrhagia  and  leucorrhea  may  be  present  as  a  re- 


RE  TROFLEXION  AND  RE  TRO  VERSION.  1 3 1 

suit  of  the  congestion  and  tlie  chronic  inflammation  of 
the  endometrium.  Menstruation  is  usually  painful.  At 
the  menstrual  period  the  backache,  headache,  ovarian 
pain,  and  vesical  disturbance  are  increased.  Dysmen- 
orrhea due  to  obstruction  is  unusual  in  cases  of  retro- 
flexion. Retroflexion  usually  occurs  in  parous  women, 
in  whom  the  cervical  canal  is  large,  and  the  flexion 
therefore  does  not  cause  sufficient  obstruction  to  impede 
the  escape  of  menstrual  blood.  All  the  symptoms  aris- 
ing from  retroversion  of  the  uterus  are  ameliorated  by 
the  recumbent  posture. 

The  diagnosis  of  retroversion  and  retroflexion  of  the 
uterus  is  very  easily  made  by  bimanual  examination. 
The  abdominal  hand  fails  to  find  the  fundus  in  the 
normal  position.  The  vaginal  finger  feels  the  cervix 
uteri  directed  not  backward  toward  the  coccyx,  but  for- 
ward in  the  direction  of  the  vaginal  axis  or  toward  the 
symphysis  pubis.  The  posterior  wall  of  the  cervix  and 
the  body  of  the  uterus  may  be  plainly  felt  inclined  back- 
ward. In  case  of  retroflexion  the  angle  of  flexion  may 
be  felt  by  the  vaginal  finger. 

The  accompanying  prolapse  of  the  ovaries  is-  usually 
very  easily  demonstrated  by  vaginal  touch. 

Treatment. — As  retroflexion  does  not  usually  cause 
obstruction  of  the  menstrual  flow,  the  treatment  need  not 
be  directed  toward  rendering  patulous  the  cervical  canal, 
as  in  the  case  of  anteflexion.  Retroflexion  is  always  as- 
sociated with  retroversion,  and  the  methods  that  correct 
the  retroversion  place  the  uterus  in  such  a  position  that 
the  intra-abdominal  pressure  acts  on  the  posterior  face 
of  the  uterus  and  gradually  reduces  the  flexion.  There- 
fore the  treatment  of  retroflexion  and  of  retroversion  may 
be  considered  together. 

Retroversion  is  treated  by  the  vaginal  pessary  and  by 
operation. 

The  vaginal  pessary  is  an  instrument  to  be  worn  in  the 
vagina,  and  designed  to  retain  the  uterus  in  its  normal 
position.      A  great  many  different  kinds  of  pessaries  have 


132       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

been  invented.  The  large  number  of  different-shaped 
instruments  proves  the  inefificacy  of  the  pessary  as  a 
means  of  treatment  in  many  cases  of  retroversion. 

The  best  pessaries  for  retroversion  are  the  Hodge  (Fig. 
90,  a),  the  Smith  (Fig.  90,  b),  and  the  Thomas  (Fig.  90, 
c).     These  instruments  are  made  of  hard  rubber.     They 


A  B 

Fig.  90. — Pessaries  for  retroversion:    A,  Hodge   pessary;    b,  Smith   pessary; 
c,  Thomas  pessary. 

consist  of  an  upper  and  a  lower  transverse  bar  joined  by 
two  lateral  bars.  They  are  so  shaped  that  when  intro- 
duced into  the  vagina  they  correspond  very  closely  to  the 
curvature  of  the  vaginal  slit. 

Fig.  91  shows  a  side  view  of  a  pessary  in  position,  and 
it  will  be  observed  that  the  curves  of  the  instrument  are 
closely  adapted  to  the  curves  of  the  posterior  vaginal 
wall,  upon  which  it  lies. 

The  vaginal  pessary  retains  the  uterus  in  place  by 
raising  the  posterior  vaginal  fornix  and  keeping  tense 
the  posterior  vaginal  wall.  It  will  be  observed  that  the 
posterior  wall  of  the  vagina  runs  over  the  upper  trans- 
verse bar  of  the  pessary  like  a  rope  over  a  pulley; 
therefore  there  is  maintained  a  continuous  traction  in 
an  upward  and  backward  direction  upon  the  cervix,  and 
a  resulting  continuous  tendency  to  throw  the  fundus  uteri 
in  a  forward  position  (Fig.  91).     The  tension  of  the  pos- 


RETROFLEXION  AND  RETROVERSION. 


133 


terior  vaginal  wall  and  the  traction  upon  the  cervix  vary 
with  the  position  and  occupation  of  the  woman,  and  are 
increased  by  anything  that  increases  the  intra-abdominal 
pressure. 

The  vaginal   pessary  does  not  maintain  the  uterus  in 
place  by  pressure  upon  the  body  of  the  uterus,  nor  does 


Fig.  91. — The  retroversion  pessary  in  position.     The  arrow  shows  the  direction 
of  the  traction  of  the  posterior  vaginal  wall  upon  the  cervix. 


the  vaginal  pessary  correct  a  retrodisplacement.  The 
uterus  should  be  restored  to  its  normal  position  as  nearly 
as  possible  before  the  pessary  is  introduced. 

Replacement  of  the  uterus  may  be  effected  in  one  of 
two  ways:  by  bimanual  reposition  while  the  woman  is 
in  the  dorsal  position;  or  by  instrumental  reposition 
while  the  woman  is  in  the  knee-chest  position. 

In  bimanual  reposition  the  uterus  is  manipulated  be- 
tween the  vaginal  finger  or  fingers  and  the  abdominal 
hand  until  the  organ  is  brought  to  its  normal  position 
of  anteversion  (Fig.  92).  Sometimes  this  may  be  more 
easily  accomplished  by  introducing  one  or  two  fingers 
into  the  rectum. 

After  bimanual  reposition  the  pessary  should  be  intro- 


134       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

duced  in  the  vagina,  and  the  upper  bar  of  the  instrument 
should  be  carried  behind  the  cervix  by  manipulation  with 
the  vaginal  finger.  . 

Bimanual  reposition  is  often  difficult  or  impossible  in 
fat  women  and  in  those  with  rigid  abdominal  walls. 


Fig.  92. — Bimanual  reposition  of  the  retroflexed  utei-us. 

Instrumental  reposition  in  the  knee-chest  position^ 
however,  is  applicable  to  all  cases  in  which  a  pessary  is 
indicated.  As  this  method  is  the  one  that  should  in 
general  be  followed,  it  will  be  described  in  detail. 

The  woman  should  be  placed  in  the  knee-chest  posi- 


FiG.  93. — Uterine  repositor. 


tion.  The  perineum  should  be  retracted  and  the  cervix 
exposed  with  a  Sims  speculum.  It  will  be  observed  that 
the  cervix  is  directed  forward  toward  the  symphysis 
pubis.  The  uterine  repositor  (Fig.  93)  is  then  intro- 
duced,   and   pressure   is  made  in   the  posterior   vaginal 


RE  TROFLEXION  AND  RE  TRO  VERSION.         135 

fornix  upon  the  displaced  fundus.  The  fundus  may  be 
felt  with  the  repositor  in  this  position.  Sometimes,  by 
grasping  the  cervix  with  a  tenaculum  and  drawing  it 
downward,  the  repositor  may  be  applied  with  better 
effect  (Fig. 94).  It  will  often  be  observed  that  under  this 
pressure  the  fundus  immediately  drops  forward,  while  the 


Fig.  94. — Replacement  of  retrodisplaced  uterus  by  means  of  the  uterine  reposi- 
tor, with  patient  in  the  knee-chest  position  (Baldy). 

cervix  is  turned  backward  through  an  angle  of  90°  or  per- 
haps 180°,  so  that  the  external  os  looks  no  longer  toward 
the  symphysis  pubis,  but  toward  the  hollow  of  the  sac- 
rum. The  direction  of  the  cervix  shows  plainly  when  the 
uterus  is  in  the  normal  position.  Instead  of  the  uterine 
repositor  we  may  use  a  small  firm  ball  of  cotton  held  in 
long  forceps. 

Sometimes  it  is  not  possible  to  make  the  entire  correc- 
tion of  the  displacement  at  one  time.  The  uterus  may 
perhaps  be  reduced  from  retroversion  of  the  third  degree 
to  that  of  the  first  degree,  and  at  a  subsequent  attempt  it 
may  be  reduced  still  more,  until  finally  it  is  brought  to 
its  normal  position.  In  some  cases  the  difiiculty  of  pro- 
ducing complete  reduction  at  one  time  is  due  to  the  fact 


136      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


that  the  woman  is  unaccustomed  to  the  position  and  the 
manipulations,  and  is  constantly  straining  and  involun- 
tarily resisting.  Complete  relaxation  of  the  abdominal 
walls  is  necessary. 

If  the  uterus  can  be  reduced  to  the  normal  position, 
the  pessary  may  be  immediately  introduced.  If  the  re- 
duction is  not  complete,  it  is  best  to 
pack  the  vagina  with  cotton  to 
maintain  the  degree  of  reduction 
that  has  been  attained,  and  to  repeat 
the  attempt  the  next  day,  continuing 
in  this  way  until  the  uterus  has  been 
brought  approximately  to  its  normal 
position,  when  the  pessary  should  be 
introduced.  The  cotton  should  be 
packed  into  the  vagina  in  the  form 
of  balls  or  pledgets  about  one  and  a 
half  inches  in  diameter,  which  should 
be  introduced  with  the  forceps  (Fig. 
95)  and  carefully  and  tightly  packed 
into  the  posterior  vaginal  fornix. 
Other  pieces  should  then  be  packed 
against  the  anterior  aspect  of  the 
cervix,  and  then  the  rest  of  the  va- 
gina should  be  rather  loosely  filled. 
The  pessary  should  be  introduced 
with  the  woman  in  the  knee-chest 
position.  A  number  of  pessaries,  of 
various  sizes  and  shapes,  should  be 
at  hand,  in  order  to  have  a  suitable 
assortment  for  choice.  The  pessary 
iG.  95.—    eiine  oiceps.   ^^^g^  j^^  ^s^  ^j^^  proper  length,  breadth, 

and  shape  ;  these  requirements  differ  in  various  cases. 
The  length  of  the  pessary  should  be  such  that  when  the 
upper  transverse  bar  lies  in  the  posterior  vaginal  fornix 
the  lower  transverse  bar  is  over  the  position  of  the  in- 
ternal urinary  meatus.  The  course  of  the  urethra  is 
marked  by  small  transverse  folds  of  mucous  membrane 


RE  TROFLEXrON  AND  RE  TRO  VERSION.         137 

on  the  middle  of  the  anterior  vaginal  wall,  and  the  in- 
ternal urinary  meatus  is  situated  approximately  where 
these  small  transverse  folds  cease  and  become  merged 
into  the  larger  oblique  folds  of  the  vaginal  walls.  This 
distance  may  be  measured  upon  the  uterine  repositor  or 
it  may  be  estimated  with  the  eye. 

It  should  be  remembered  that  all  the  dimensions  of  the 
vagina  are  exaggerated  in  the  knee-chest  position,  as  the 
vaginal  canal  is  distended  by  atmospheric  pressure.  The 
width  of  the  pessary  should  be  such  that  there  is  no 
lateral  tension  put  upon  the  vaginal  walls. 

The  curvature  of  the  pessary  should  be  such  that  the 
upper  transverse  bar  does  not  press  upon  the  posterior 
aspect  of  the  cervix,  but  is  so  placed  that  the  posterior 
vaginal  fornix  is  drawn  upward  and  backward. 

The  curvature  of  the  pessary  may  be  altered  to  suit 
any  case  by  dipping  the  instrument  in  oil  and  gently 
heating  it  over  the  flame  of  a  spirit-lamp.  In  this  way 
the  rubber  is  softened  and  may  be  pressed  into  any  shape. 
While  soft  and  under  pressure  it  should  be  plunged  into 
cold  water  to  set  it  in  the  altered  form. 

The  pessary  may  be  introduced  while  the  perineum  is 
retracted  with  the  speculum;  or  it  may  be  passed  into 
the  vagina  first,  the  speculum  then  being  introduced  and 
the  pessary  moved  into  the  proper  position.  The  pessary 
should  be  greased,  the  lower  transverse  bar  should  be 
grasped  with  the  thumb  and  the  index  finger,  and  the 
instrument  should  be  introduced  in  such  a  direction  that 
.one  lateral  bar  lies  in  the  vaginal  sulcus.  The  upper 
transverse  bar  may  readily  be  placed  behind  the  cervix, 
by  manipulation  with  the  finger  or  the  forceps,  when  the 
•perineum  is  retracted  with  the  speculum. 

The  speculum  should  be  removed,  and  the  woman 
:should  assume  the  Sims  posture  for  a  few  minutes.  She 
-may  then  get  up  from  the  table,  and  the  examination 
-may  be  made  in  the  erect  posture,  for  in  this  position, 
better  than  in  any  other,  the  fit  and  the  action  of  the 
-pessary  may  be  determined.      It  will  be  found  that  the 


138       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

lower  bar  of  the  pessary  is  in  relation  with  the  anterior 
vaginal  wall  at  the  position  of  the  internal  urinary 
meatus.  It  should  not  protrude  from  the  ostium  vagi- 
nae. It  should  be  possible  to  pass  the  finger  readily 
between  the  vaginal  walls  and  the  lateral  and  lower 
bars  of  the  pessary.  The  cervix  should  be  felt  directed 
backward  through  the  upper  portion  of  the  ring  of  the 
pessary.  It  will  be  felt  that  the  pessary  is  retained  iu 
the  vagina  not  by  any  pressure  against  the  vaginal  walls, 
but  by  a  suction — in  other  words,  by  the  retentive  power 
of  the  abdomen. 

A  vaginal  douche  of  warm  water  should  be  adminis- 
tered once  a  day  while  the  pessary  is  worn. 

The  woman  should  be  directed  to  return  for  examina- 
tion three  days  after  the  introduction  of  the  pessary,  or 
sooner  if  any  discomfort  is  experienced.  Sometimes  the 
uterus  becomes  retroverted  while  the  pessary  is  in  posi- 
tion, and  becomes  flexed  over  the  upper  bar  of  the  instru- 
ment, considerable  pain  resulting.  In  other  cases,  where 
the  vagina  is  patulous  and  too  small  an  instrument  is 
used,  the  pessary  becomes  turned  so  that  the  long  axis  lies 
transversely.  It  is  well  to  advise  the  woman  to  remove  the 
instrument  herself  if  it  makes  her  very  uncomfortable. 

The  pessary  should  be  examined  digitally  in  the  dorsal 
or  the  erect  position,  or  visually  in  the  knee-chest  posi- 
tion. If  it  is  found  that  the  retroversion  has  returned, 
the  uterus  should  be  replaced  and  a  pessary  better  suited 
in  size  and  shape  should  be  introduced.  It  is  always 
desirable  to  use  as  small  an  instrument  as  practicable. 
The  intervals  between  examinations  may  be  gradually 
lengthened  to  two  weeks  or  a  month.  A  woman  using 
a  pessary  should  always  be  under  the  supervision  of  a 
physician.  The  retroversion  pessary  does  not  interfere 
with  sexual  connection. 

The  bowels  should  be  carefully  regulated.  The  cloth- 
ing should  be  supported  from  the  shoulders,  not  from  the 
waist,  and  heavy  lifting  should  be  avoided  as  much  as 
possible. 


RE  TROFLEXION  AND  RE  TRO  VERSION.        139 

After  a  woman  has  worn  a  pessary  for  three  or  four 
months,  and  it  is  found  that  the  uterus  remains  in  the 
normal  position,  the  instrument  should  be  removed  and 
the  result  carefully  watched. 

If  the  uterus  continues  in  its  normal  position  of  ante- 
version,  a  cure  has  been  accomplished  and  the  pessary 
may  be  discarded.  If  the  retroversion  returns,  as  it  very 
often  does,  the  pessary  should  be  introduced  again,  and 
an  unfavorable  prognosis  of  cure  by  this  means  should  be 
made.  The  patient  must  then  choose  between  the  use  of 
the  pessary  for  an  indefinite  period,  under  medical  super- 
vision, and  cure  by  means  of  an  operation. 

The  Smith  pessary  is  better  adapted  to  the  shape  of 
the  vagina,  which  normally  narrows  from  above  down- 
ward, than  is  the  Hodge  instrument.  The  Thomas  pes- 
sary, in  which  the  upper  bar  is  made  very  broad,  is  appli- 
cable to  cases  of  sharp  retroflexion  with  retroversion,  in 
which  the  upper  bar  may  become  fixed  in  the  angle  of 
flexion  in  case  the  retroversion  returns.  The  upper  bar 
is  made  so  broad  that  the  angle  of  flexion  would  be 
spanned  by  it  in  case  of  such  an  accident. 

The  action  of  the  pessary  depends  upon  the  integrity 
of  the  vagina  and  the  pelvic  floor.  The  retroversion 
pessary,  therefore,  cannot  be  used  when  there  is  a  lacera- 
tion of  the  perineum.  In  such  a  case  the  perineum  must 
always  be  closed  as  a  preliminary  step. 

The  pessary  should  not  be  used  when  there  is  a  lacera- 
tion of  the  cervix  uteri,  for  traction  upon  the  posterior 
lip  of  the  cervix  increases  the  eversion. 

The  pessary  is  contraindicated  in  all  cases  in  which 
there  are  pelvic  adhesions  restraining  the  uterus,  in  those 
cases  in  which  there  is  inflammatory  disease  of  the  Fal- 
lopian tubes,  and  in  cases  where  there  is  prolapse  of  the 
ovary,  which  may  be  pressed  upon  by  the  upper  bar  of 
the  pessary. 

Before  making  any  attempt  to  replace  a  displaced 
uterus  the  physician  should  always  make  a  careful  bi- 
manual examination  to  determine  the  existence  of  any 


I40      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN-. 

acute  or  chronic  inflammation  of  the  Fallopian  tubes  or 
the  ovaries.  Such  inflammation  is  a  contraindication  to 
the  use  of  the  pessary  and  to  any  of  the  manipulations 
for  replacement  of  the  uterus  that  have  already  been 
described. 

If  the  uterus  is  adherent,  the  pessary  should  not  be 
used.  Cure  of  the  retroversion  by  it  is  practically  im- 
possible, and  operative  treatment  is  safer  and  more 
certain. 

Operative  Means  of  Treating  Retrodisplacement 
of  the  Uterus. — A  great  many  kinds  of  operation  have 
been  introduced  for  curing  retrodisplacement  of  the  ute- 
rus. The  fundus  has  been  attached  to  the  anterior  ab- 
dominal wall  by  passing  a  needle  and  a  suture  into  the 
uterus  and  thrusting  it  through  the  uterine  wall  and  the 
anterior  abdominal  wall;  the  uterine  cornua  have  been 
sutured  to  the  anterior  parietes  ;  the  round  ligaments 
have  been  shortened  by  folding  each  upon  itself,  and  fixed 
in  this  position  by  suture;  the  uterus  has  been  held  for- 
ward by  sutures  applied  through  the  anterior  vaginal 
fornix. 

The  two  operations  that  have  deservedly  met  with  the 
greatest  favor  are  ventro-fixation  or  ventro-suspension  of 
the  uterus,  in  which  the  abdomen  is  opened  and  the  fun- 
dus is  sutured  directly  to  the  anterior  abdominal  wall, 
and  Alexander's  operation,  in  which  the  uterine  displace- 
ment is  corrected  by  shortening  the  round  ligaments  as 
they  emerge  from  the  inguinal  rings.  The  latter  opera- 
tion is  designed  to  be  extra-peritoneal.  The  following  is 
the  method  of  performing  Alexander's  operation: 

The  uterus  should  first  be  replaced  as  already  described, 
and  held  in  position  by  a  gauze  or  cotton  pack.  A  two- 
inch  incision  is  made  from  the  pubic  spine  in  the  direc- 
tion of  the  inguinal  canal.  The  external  inguinal  ring 
is  opened  without  wounding  the  pillars.  The  thin  layer 
of  fascia  over  the  ring  is  divided,  the  fat  is  separated, 
and  the  round  ligament  is  sought  with  a  blunt  hook.  If 
the  ligament  is  not  found  here,  the  canal  may  be  opened 


RE  TROFLEXION  AND  RE  TRO  VERSION.  141 

to  the  internal  ring.  When  one  ligament  has  been  found, 
it  is  secured  with  forceps  and  the  wound  is  protected 
while  the  other  ligament  is  secured  in  a  similar  way. 
The  ligaments  are  then  gently  drawn  out  until  they  be- 
come tense.  If  the  inguinal  canal  has  been  opened,  it 
should  be  repaired  by  a  catgut  suture. 

The  ligament  should  be  sutured  to  the  pillars  of  the 
ring  by  two  or  three  sutures.  The  excess  of  the  liga- 
ment, sometimes  amounting  to  two  or  three  inches,  should 
be  cut  off.     The  incision  should  then  be  closed. 

The  field  of  this  operation  is  very  limited.  It  is  not 
applicable  when  there  are  adhesions  nor  when  there  is 
disease  of  the  tubes  or  ovaries  requiring  operative  treat- 
ment. 

Many  of  the  cases  of  retroversion  of  the  uterus  that 
require  operative  treatment  are  complicated  by  salpin- 
gitis and  pelvic  adhesions,  though  these  extra-uterine 
conditions  are  very  often  not  recognized  by  bimanual 
examination  before  the  abdomen  is  opened. 

The  operation  that  at  present  seems  to  possess  most 
advantages  for  the  cure  of  those  cases  of  retroversion  of 
the  uterus  that  cannot  be  cured  by  the  pessary  is  the 
operation  of  ventro-suspension  of  the  uterus  (Fig.  96). 
It  is  performed  as  follows: 

An  incision,  one  and  a  half  to  three  inches  in  length, 
is  made  in  the  median  line  of  the  anterior  abdominal 
wall,  immediately  above  the  pubis.  Two  fingers  are 
introduced  into  the  abdominal  cavity,  and  the  fundus 
uteri  is  lifted  forward.  The  plane  of  the  abdominal 
incision  is  exposed,  and  a  curved  needle  carrying  a  me- 
dium-sized silk  suture  is  passed  through  a  few  fibers  of  the 
rectus  muscle  and  the  peritoneum  on  one  side,  immedi- 
ately above  the  lower  angle  of  the  incision.  The  needle 
is  then  passed  through  the  tissue  of  the  fundus  uteri  on 
the  line  joining  the  uterine  cornua  or  a  little  posterior  to 
this  line.  The  amount  of  uterine  tissue  included  in  the 
suture  is  about  one-quarter  of  an  inch  broad  and  one- 
eighth   to  one-quarter  of  an  inch  deep.     The  needle  is 


143       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

then  passed  through  the  peritoneum  and  a  few  fibers  of 
the  rectus  muscle  on  the  side  of  the  abdominal  incision 
opposite  the  point  of  entrance.  A  similar  suture  is  passed 
about   one-third  of  an  inch  above   this,    traversing   the 


Fig.  96. — Position  of  the  sutures  in  ventro-suspension  of  the  uterus. 


Uterine  wall  on  a  line  about  one-third  of  an  inch  poste- 
rior to  the  first  suture.  While  the  fundus  is  held  forward 
by  the  finger  of  an  assistant  these  sutures  are  tied,  so 
that  the  fundus  uteri  is  brought  into  contact  with  the 
anterior  abdominal  wall.  The  ends  of  the  sutures  are 
cut  short.  The  abdominal  incision  is  then  closed  by 
three  layers  of  sutures — silk  for  the  peritoneum,  catgut 
for  the  muscle  and  fascia,  and  the  intra-cutaneous  suture 
for  the  skin.  Accompanying  disease  of  the  tubes  and 
ovaries  may  be  treated  directly  by  this  operation,  and  any 
adhesions  may  readily  be  broken. 

In  performing  this  operation  it  should  be  remembered 
that  we  do  not  wish  to  make  a  fixation  of  the  uterus  to 


RE  TROFLEXION  AND  RE  TRO  VERSION.         143 

the  anterior  abdominal  wall.  The  inclusion  of  a  broad 
mass  of  uterine  tissue  in  the  suture,  and  scarification  of 
the  anterior  face  of  the  uterus,  which  is  sometimes  prac- 
tised, may  result  in  a  broad,  unyielding  adhesion  which 
will  interfere  with  the  normal  mobility  of  the  uterus  and 
with  the  course  of  pregnancy  and  labor. 


Fig.  97. — The  suspensory  ligament  two  years  after  the  operation  of  ventro-sus- 
pension.     The  ligament  measured  three  inches  in  length. 

Aftef  the  operation  of  ventro-suspension  the  fundus 
uteri  does  not  remain  permanently  in  contact  with  the 
anterior  abdominal  wall.  In  time  it  drops  somewhat 
backward  and  downward.  The  silk  sutures  drag  out  a 
ribbon-shaped  fold  of  tissue  consisting  of  peritoneum  and 
a  little  muscle-fiber  from  the  anterior  abdominal  wall, 


144       A   TEXT- BOOK  OF  DISEASES  OF  WOMEN. 

and  a  similar  fold  of  peritoneum  and  perhaps  some  mus- 
cular fibers  from  the  uterus,  so  that  in  time  the  uterus 
becomes  attached  by  a  slight  pliable  ligament  from  one 
to  three  inches  in  length  (Fig.  97).  Bimanual  examina- 
tion of  the  uterus  one  year  after  this  operation  shows 
that  the  uterus  has  about  the  normal  range  of  mobility. 
If  this  operation  is  properly  performed,  the  course  of  sub- 
sequent pregnancies  and  labors  seems  to  be  in  no  way  im- 
peded. 

The  operation  of  ventro-suspension  should  always  be 
accompanied  by  perineorrhaphy  in  case  there  has  been 
laceration  of  the  perineum.  The  two  operations  may 
be  done  at  the  same  time. 

The  treatment  of  retrodisplacement  of  the  uterus  may 
be  briefly  summarized  as  follows: 

The  cases  of  retrodisplacement  of  the  uterus  suitable 
for  treatment  by  the  pessary  are  those  in  which  there  are 
no  adhesions  and  in  which  there  is  no  disease  of  the  Fal- 
lopian tubes  or  the  ovaries.  If  a  prolapsed  ovary  returns 
to  its  normal  position  when  the  displacement  of  the  uterus 
is  corrected,  it  will  of  course  not  be  pressed  upon  by  the 
bar  of  the  pessary.  But  in  some  cases  the  ovarian  pro- 
lapse continues  even  though  the  uterus  is  in  its  normal 
position,  and  under  such  circumstances  a  pessary  usually 
cannot  be  tolerated. 

The  cases  that  offer  the  best  prospect  of  cure  by  the 
pessary  are  those  cases  of  retroversion,  occurring  as  the 
result  of  labor,  in  which  the  perineum  is  intact,  and 
which  are  seen  within  one  or  two  years  after  the  occur- 
rence of  the  lesion.  The  prognosis  becomes  more  un- 
favorable according  to  the  duration  of  the  condition 
before  treatment. 

Cases  of  congenital  retroversion,  or  those  occurring  in 
young  unmarried  women,  are  very  difficult  to  cure  with 
the  pessary.  This  instrument  should  always  be  tried  for 
a  few  months,  however,  before  operative  measures  are 
advised.  In  such  cases  the  uterus  has  been  so  long  in  an 
abnormal  position  that  its  natural  supports  have  become 


RETROFLEXION  AND  RETROVERSION.         145 

permanently  altered,  and  some  continuoiLs  additional  aid 
is  necessary  to  maintain  the  normal  position. 

Every  woman  who  uses  a  pessary  should  be  under  the 
supervision  of  a  physician,  and  for  this  reason  it  is  often 
most  advisable  to  recommend  immediate  operation  to 
poor  women  as  the  quickest  and  surest  method  of  cure. 

Immediate  operation  should  always  be  advised  in  all 
cases  of  retroversion  with  adhesion  or  with  disease  of 
the  tubes  and  ovaries. 

It  should  not  be  forgotten  that  we  occasionally  see 
women  with  retroversion  of  the  uterus  who  present  no 
symptoms  whatever  referable  to  this  lesion.  In  such 
cases  no  treatment  is  required. 

Note. — The  operation  of  ventro-suspension  as  described  above  has  been 
done  by  the  writer  and  his  assistants  310  times  during  the  past  seven  years, 
1893-1901.  Two  hundred  and  eleven  of  these  women  have  recently  made 
written  reports  of  their  condition,  which   are   tabulated  as  follows  : 


Number  of  cases 
relieved  of  the 
symptoms  for 
which  treatment 
was  sought. 

^   > 

It 

"o2 

II 
1^ 

Number  of  cases 
who  became 
pregnant  and 
went  to  full  term. 

Sis' 

m  u 

^  c3 

II 

Ventro-suspension  with  unilateral  salpingo-  \ 
oophorectomy.                                                       j 

Ventro-suspension  with  perineorrhaphy  and  | 
trachelorrhaphy.                                                   J 

Ventro-suspension  with  perineorrhaphy. 

Ventro-suspension  with  trachelorrhaphy. 

Ventro-suspension  alone. 

20 

34 
22 
20 

35 

7 

IS 
12 
6 

9 

7 

s 

8 

5 
6 

I 
6 

4 
4 

5 

0 

3 
I 
4 
0 

131 

49 

31 

20 

8 

Of  the  20  women  who  became  pregnant  and  went  to  full  term,  the  course 
of  pregnancy  was  normal,  and  the  children  were  all  born  alive.  One  woman 
had  a  prolonged  and  difficult  labor,  though  forceps  were  not  used.  In  i  case 
forceps  were  used  to  deliver  a  ten-pound  child,  who  presented  in  occipito-pos- 
terior  position;  in  the  remaining  18  cases  labor  was  normal. 

The  operation  of  ventro-suspension  seems  to  have  had  nothing  whatever  to  do 
with  producing  the  miscarriages.     In  fact,  the  number  of  miscarriages  is  small 
for  any  series  of  21 1   women,  most  of  whom  were  of  the  dispensary  class. 
10 


CHAPTER   XII. 
LACERATION  OF  THE  CERVIX  UTERI. 

Laceration  of  the  neck  of  the  uterus  is  of  very  fre- 
quent occurrence.  It  is  said  that  nearly  every  woman 
suffers  with  a  laceration  of  greater  or  less  extent  at  her 
first  labor.  The  majority  of  such  lacerations,  however, 
undoubtedly  heal  during  the  puerperium  and  give  no 
subsequent  trouble.  The  lacerations  that  concern  the 
gynecologist  are  those  that  persist,  remaining  ununited 
after  the  woman  leaves  her  bed.  The  description  of  the 
injured  parts  and  the  treatment  therefor  will  be  applica- 
ble to  such  old  cases  of  laceration.  It  is  true  that  some 
gynecologists  have  advised  immediate  examination  and, 
the  primary  operation  for  repair  in  case  of  laceration  of 
the  cervix,  as  in  case  of  injury  to  the  perineum;  but  such 
a  course  has  at  present  but  little  endorsement.  It  is  dif- 
ficult to  obtain  a  satisfactory  examination  under  such 
circumstances.  A  digital  examination  alone,  unless  the 
sense  of  touch  be  very  acute,  would  often  fail  to  detect 
the  lesion  in  the  soft  cervical  tissue.  The  woman  is 
exposed  to  the  danger  of  infection  of  the  upper  genital 
tract  from  the  manipulations  of  the  examination  and  the 
operation,  and  such  exposure  may  be  unnecessary,  be- 
cause there  is  no  doubt  that  many  lacerations  of  the 
cervix  unite  of  themselves. 

It  has  been  found  necessary  to  perform  the  operation 
immediately  after  labor  on  account  of  severe  hemor- 
rhage from  the  lacerated  wound. 

Laceration  of  the  cervix  may  take  place  in  any  direc- 
tion, and  the  injury  is  described  according  to  the  direc- 
tion and  number  of  the  tears.     A  lateral  laceration  takes. 

146 


LACERATION  OF  THE  CERVIX  UTERI. 


147 


place  on  either  side  of  the  cervix.  A  bilateral  laceration 
involves  both  sides  (Fig.  104,  a).  The  left  is  the  more 
usual  lateral  laceration  (Fig.  98),  and  in  case  of  a  bilateral 
tear  the  injury  on  the  left  side  is  usually  the  more  exten- 
sive.    The  stellate  laceration  (Fig.  99)  occurs  when  three 


m**^  *"^- J*«5-^ 

if 

W^^^^ 

k 

* 

/ 

Fig.  98. — Left  lateral  laceration  of  the  cervix     Fig.  99. — Stellate  laceration  of 
with  erosion.  the  cervix. 


or  more  lacerations  radiate  from  the  cervical  canal.  The 
less  common  varieties  of  laceration  seen  by  the  gyne- 
cologist are  through  the  anterior  and  through  the  poste- 
rior lip.  It  may  be  that  such  lacerations  occur  as  often  as 
the  lateral  lacerations,  and  that  spontaneous  repair  more 
often  occurs,  so  that  they  produce  no  subsequent  trouble. 
The  relations  of  the  neck  of  the  uterus  are  such  that 
accurate  apposition  of  the  injured  parts  is  more  likely  to 
occur  in  case  of  antero-posterior  laceration  than  in  the 
lateral  form  of  the  injury.  In  some  cases  there  seems  to 
be  no  doubt  that  the  laceration  has  extended  through  the 
posterior  lip  of  the  cervix  into  the  cellular  tissue  above 
the  posterior  vaginal  fornix,  and  that  spontaneous  repair 
has  taken  place,  leaving  a  dense  band  of  scar-tissue  to 
mark  the  site  of  the  lesion. 

An  incomplete  laceration  of  the  cervix  is  sometimes 
found.  In  this  injury  the  tear  has  extended  but  part  way 
through  the  wall  of  the  cervix.     The  mucous  membrane 


148      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

of  the  cervical  canal  and  the  muscular  wall  of  the  cervix 
are  lacerated,  but  the  injury  does  not  involve  the  mucous 
membrane  of  the  vaginal  aspect,  beyond,  perhaps,  a  slight 
splitting  of  the  external  os  (Fig.  100).    The  lesion  is  thus 


Fig.  100. — Incomplete  laceration  of  the  cervix. 

concealed,  and  separation  of  the  portions  of  the  cervix  is 
prevented.  The  injury  may  be  detected  by  introducing 
a  sound  in  the  cervical  canal  and  placing  a  finger  on  the 
vaginal  aspect  of  the  cervix,  when  it  will  be  found  that 
at  this  spot  the  point  of  the  sound  and  the  finger  are 
separated  only  by  the  thickness  of  the  vaginal  mucous 
membrane,  and  not  by  the  normal  thickness  of  the  wall 
of  the  cervix. 

The  appearance  of  a  lacerated  cervix  varies  with  the 
time  that  has  elapsed  since  the  receipt  of  the  injury.  A 
few  weeks  or  months  after  the  occurrence  the  torn  por- 
tions of  the  cervix  will  be  found,  by  sight  or  touch,  ly- 
ing in  more  or  less  close  apposition,  the  general  conical 
shape  of  the  cervix  being  unaltered.  After  the  lapse  of 
a  longer  period,  however,  the  edges  of  the  laceration  be- 
come rounded,  and  a  certain  amount  of  eversion,  or  turn- 
ing out,  of  the  portions  of  the  cervix  takes  place,  so  that 
the  mucous  membrane  of  the  cervical  canal  becomes  ex- 
posed. This  eversion  is  always  most  pronounced  in  the 
bilateral  laceration,  and  is  especially  striking  when  the 
tear  has  extended  entirelv  through  the  cervix  into  the  lat- 


LACERATION  OF  THE  CERVIX  UTERI 


149 


eral  vaginal  fornices.  In  such  cases  the  cervix  assumes  the 
shape  of  a  split  stalk  of  celery  (Fig.  loi).  The  cases  of 
laceration  with  eversion  of  the  lips  are  those  in  which 
the  most  marked  symptoms  are  found.  When  eversion 
occurs,  and  the  mucous  membrane  of  the  cervical  canal  is 
exposed,  the  shape  and  ap- 
pearance of  the  cervix  are 
very  much  altered  from  the 
normal.  Before  the  true  na- 
ture of  this  lesion  had  been 
pointed  out  by  Bmmet  such 
a  cervix  was  said  to  be  ul- 
cerated, the  raw-looking  sur- 
face, corresponding  to  the  ex- 
posed, irritated,  and  inflamed 
mucous  membrane  of  the  cer- 
vical canal,  having  been  mis- 
taken for  an  ulcer.  Even  at 
the  present  day  such  a  mis- 
take is  not  infrequently 
made. 

Microscopical  examination 
of  such  raw-looking  surfaces 
shows  that  they  are  in  no 
sense  ulcers.  "The  surface 
is  covered  with  a  single  layer  of  epithelium;  the  cells 
are  smaller  than  those  which  line  the  normal  cervical 
canal,  and,  being  narrow  and  long,  have  a  palisade-like 
arrangement;  the  thin  layer  of  cells  allows  the  subjacent 
vascular  tissue  to  shine  through,  hence  the  redness  of 
color.  The  surface  is  further  thrown  into  numerous 
folds,  producing  glandular  recesses  and  processes;  these 
processes  cause  the  granular  appearance  of  the  surface" 
(Hart  and  Barbour). 

These  red  patches  are  larger  than  the  surface  of  the 
everted  mucous  membrane  of  the  cervical  canal ;  they  are 
continuous  with,  but  extend  beyond  the  limits  of,  this 
mucous  membrane.      It  is  said  that  this  increase  is  occa- 


FiG.  loi. — Bilateral  laceration  of 
the  cervix  with  eversion.  The  dot- 
ted line  shows  the  normal  shape  of 
the  cervix. 


150      A   TEXT-BOOK  OF  DISEASES  OF  UlDAfEN. 

sioned  by  proliferation  of  the  epithelium  that  lines  the 
cervical  glands. 

As  a  substitute  for  the  misleading  term  "ulceration," 
applied  to  this  condition,  there  have  been  proposed  the 
terms  "erosion,"  "ectropion,"  or  "  eversion "  of  the 
mucous  membrane,  and   "catarrhal  patch." 

A  true  ulcerated  surface  is  sometimes  found  on  a  lace- 
rated cervix  as  a  result  of  excessive  irritation,  but  such  a 
condition  is  rare. 

As  the  laceration  occurs  in  the  cervix  before  involu- 
tion has  begun,  this  process  is  impeded,  so  that  a  state 
of  subinvolution  of  the  cervix  results,  and  the  part  re- 
mains hypertrophied  or  much  larger  than  normal. 

The  cervical  glands  share  in  this  condition  of  subinvo- 
lution, retaining  much  of  the  increased  size  and  activity 
that  are  normal  in  the  pregnant  state. 

Changes  due  to  chronic  congestion  and  inflammation 
also  take  place.  The  connective  tissue  increases  in 
amount,  and  the  cervix  becomes  hard,  indurated,  or 
sclerotic. 

The  racemose  glands,  which  open  upon  the  cervical 
mucous  membrane,  become  inflamed,  and,  as  a  result  of 
change  in  the  consistency  of  the  glandular  secretion 
or  of  obstruction  of  the  gland-orifices,  retention  takes 
place,  with  the  production  of  small  cysts  called  Nabothian 
cysts.  Such  cysts  often  extend  peripherally,  so  that  the 
distal  end  of  the  occluded  gland  approaches  the  vaginal 
aspect  of  the  cervix,  and  appears  beneath  the  mucous 
membrane  as  a  translucent  vesicle  about  the  size  of  a 
small  pea.  Puncture  of  such  a  vesicle  permits  the  escape 
of  a  drop  of  gelatinous  fluid. 

The  whole  of  the  body  of  the  cervix  may  be  filled  with 
innumerable  cysts  of  this  kind,  of  varying  size.  When 
projecting  beneath  the  mucous  membrane  they  feel  like 
small  shot  imbedded  in  the  cervix.  A  cervix  in  this 
condition  is  said  to  have  undergone  cystic  degeneration. 
The  inflammation  of  the  lower  exposed  portion  of  the 
mucous  membrane  of  the  cervical  canal  extends  upward, 


LACERATION  OF  THE  CERVIX  UTERI.  151 

SO  that  a  condition  of  general  chronic  cervical  catarrh 
results.  This  exceedingly  common  disease  is  usually 
caused  by  laceration  of  the  cervix. 

The  focus  of  continuous  irritation  in  the  cervix  inter- 
feres with  the  normal  involution  of  the  body  of  the 
uterus,  so  that  there  occurs  a  condition  of  uterine  subin- 
volution, which  may  be  the  cause  of  the  chief  symptoms 
with  which  the  woman  suffers.  The  endometrium  shares 
in  the  subinvolution,  and,  as  a  consequence  of  this,  and 
perhaps  also  from  extension  of  inflammation  from  the 
cervical  mucous  membrane,  various  forms  of  endometritis 
may  occur. 

In  some  cases  of  laceration  of  the  cervix  no  groove 
corresponding  to  the  angle  of  the  laceration  can  be  felt 
or  seen,  because  it  has  been  filled  with  a  plug  or  mass  of 
cicatricial  tissue.  In  such  cases  this  plug  of  scar- tissue 
may  be  felt,  distinguished  by  the  palpating  finger  from 
the  softer  surrounding  tissues  of  the  cervix. 

Symptoms. — The  symptoms  of  laceration  of  the  cer- 
vix uteri  are  usually  referable  to  pathological  conditions 
that  are  secondary  to  the  laceration,  and  are  in  no  way 
characteristic.  Leucorrhea,  or  a  discharge  from  the  ex- 
posed and  inflamed  cervical  mucous  membrane,  is  usually 
present.  Menstruation  is  often  irregular,  and  is  increased 
in  duration  and  amount  as  a  result  of  the  subinvolution 
of  the  uterus  and  the  chronic  congestion,  and  perhaps 
inflammation,  of  the  endometrium.  Backache  and  ver- 
tical headache  may  also  be  present  from  the  same  cause. 

If  the  tear  is  at  all  extensive — and  especially  if  it  ex- 
tends through  the  cervix  into  the  cellular  tissue  of  the 
broad  ligament — ^pelvic  pain,  referred  to  the  general  po- 
sition of  the  scar,  may  be  experienced. 

Movement  of  the  cervix  or  of  the  uterus  that  causes  trac- 
tion upon  the  scar  in  the  broad  ligament  produces  pain. 
Such  pain  may  result  from  the  bimanual  examination, 
from  jarring  or  movements  of  the  body,  from  defecation, 
or  from  coitus. 

Much  of  the  pelvic  pain  with  which  women  suffer  in 


152       A    TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

laceration  of  the  cervix  is  probably  due  to  the  pelvic 
lymphangitis  and  lymphadenitis  that  are  caused  by  the 
continuous  irritation  of  the  diseased  cervix. 

Sterility  is  a  not  unusual  accompaniment  of  laceration 
of  the  cervix.  It  may  be  due  to  the  malposition  of  the 
external  os  or  to  the  profuse  cervical  discharges.  In  case 
conception  occurs,  abortion  may  follow  on  account  of 
the  pathological  condition  of  the  body  of  the  uterus  and 
of  the  endometrium. 

Sometimes  very  marked  reflex  nervous  disturbances  are 
caused  by  a  laceration  of  the  cervix.  Such  disturbances 
are  most  pronounced  in  those  cases  in  which  there  is 
much  cicatricial  tissue,  and  in  those  in  which  the  cervix 
is  hard  and  sclerotic  or  cystic  as  a  result  of  long-standing 
inflammation — in  other  words,  in  those  cases  in  which 
the  substance  of  the  cervix  is  most  affected. 

Neuralgia  may  occur  in  any  part  of  the  body.  It  is 
usually  situated  in  the  pelvis,  or  it  ma}^  extend  to  the 
groin  and  down  the  thigh.  Reflex  nausea  and  vomiting 
may  result  from  this  as  from  other  lesions  of  the  uterus. 
Cataleptic  convulsions  and  neurasthenia  may  also  result 
from  an  old  laceration  of  the  cervix.  The  pelvic  focus 
of  irritation  is  constantly  wearing  and  exhausting  nerv- 
ous energy. 

Diagnosis. — The  diagnosis  of  laceration  of  the  cervix 
is  readily  made  by  digital  examination.  The  palpating 
finger  feels  the  one  or  more  angles  of  laceration.  The 
cervix  loses  its  normal  dome-like  shape  and  becomes 
broader  and  flatter.  In  those  cases  of  bilateral  laceration 
where  the  eversion  of  the  lips  of  the  cervix  is  so  marked 
that  the  angles  of  laceration  are  obliterated — becoming, 
in  fact,  180  degrees — or  where  the  angles  have  become 
filled  up  by  a  plug  of  cicatricial  tissue,  the  angles  of 
the  laceration,  of  course,  cannot  be  felt.  We  may  often, 
however,  detect  the  presence  of  the  plug  of  cicatricial 
tissue,  which  feels  harder  than  the  surrounding  tissues 
of  the  cervix;  and  we  can  always  determine  the  presence 
of  the  eversion  which  seems  to  have  obscured  the  lesion. 


LACERATION  OF  THE  CERVIX  UTERI.  153 

As  the  finger  is  passed  over  the  flattened  presenting 
cervix  it  is  found  that  the  shape  is  not  round,  but  oval, 
with  the  long  axis  antero-posterior.  The  finger  passes 
around  a  corner  or  edge  as  it  glides  into  the  anterior  or 
posterior  vaginal  fiDrnix.  This  corner  or  edge  is  the 
extremity  of  the  torn  everted  lip  of  the  cervix.  It  corre- 
sponds approximately  v^ith  the  margin  of  the  normal 
external  os.  The  apparent  external  os,  or  the  opening 
of  the  cervical  canal,  which  occupies  the  center  of  the 
presenting  cervix,  is  really  a  part  of  the  cervical  canal 
higher  up  than  the  normal  os — -a  part  of  the  canal  that 
has  been  exposed  by  the  laceration  and  separation  of  the 
lips.  This  fact  should  be  remembered  when  the  length  of 
the  uterus  is  measured  by  the  sound.  The  measurement 
taken  from  the  apparent  external  os  is  often  half  an  inch, 
or  even  one  inch,  less  than  it  would  be  if  the  cervix  were 
restored.  The  degree  of  subinvolution  of  the  uterus 
indicated  by  the  measurement  of  the  length  is  often, 
therefore,  considerably  greater  than  would  be  supposed 
after  such  imperfect  measurement. 

The  presence  of  an  erosion  on  the  face  of  the  cervix 
may  also  be  determined  by  palpation.  The  eroded  sur- 
face has  a  soft  and  somewhat  velvety  feeling,  in  contrast 
with  the  smooth  surface  of  the  normal  vaginal  cervix 
covered  with  squamous  epithelium. 

The  cystic  degeneration  is  readily  detected  by  feeling 
the  small  shot-like  cysts  that  cover  the  cervix;  and  the 
sclerotic  condition  is  indicated  by  the  increased  hardness 
or  induration,  which  is  easily  perceptible  to  the  finger. 

The  most  satisfactory  visual  examination  of  a  lacerated 
cervix  is  made  through  the  Sims  speculum,  with  the 
woman  in  the  Sims  or  the  genu-pectoral  position.  The 
bivalve  speculum,  by  separating  the  upper  vaginal  walls, 
often  increases  the  eversion  of  the  lips  and  masks  the 
lesion. 

The  nature  of  the  injury  in  cases  of  bilateral  lacera- 
tion with  eversion  may  readily  be  proved  in  examining 
through  the  Sims  speculum.     If  the  anterior  and  poste- 


154      A   TEXT- BOOK  OF  DISEASES  OF  WOMEN. 

rior  lips  of  the  cervix  be  seized  with  tenacula  and  then 
drawn  together,  it  will  be  observed  that  the  area  of 
erosion  disappears  and  the  normal  shape  of  the  cervix  is 
approximately  restored. 

Treatment. — All  forms  of  laceration  of  the  cervix  in 
which  there  exist  eversion,  erosion,  cystic  degeneration, 
and  sclerosis  should  be  operated  upon.  A  slight  laceration 
in  a  young  woman  in  the  active  childbearing  period  does 
not  demand  operative  treatment  if  there  are  no  symptoms 
referable  to  the  laceration.  In  women  approaching  mid- 
dle life  (forty  years  of  age)  all  lacerations  of  the  cervix 
should  be  closed,  whether  or  not  they  produce  symptoms. 
It  should  always  be  remembered  that  cancer  of  the  cervix 
is  most  likely  to  originate  in  an  old  laceration,  and  the 
woman  should  be  protected  against  this  danger. 

The  treatment  of  laceration  of  the  cervix  is  operative. 
A  definite  mechanical  injury  has  been  inflicted,  and  the 
parts  must  be  repaired  by  operation. 

The  operation  for  the  repair  of  a  lacerated  cervix  is 
called  trachelorrhaphy.  The  operation  consists  in  denud- 
ing or  excising  the  tissues  on  the  torn  surfaces  and  bring- 
ing the  freshened  surfaces  together  with  sutures. 

The  form  of  the  operation  for  a  bilateral  laceration  is 
shown  in  Fig.  104.  The  operation  should  preferably  be 
performed  immediately  after  a  menstrual  period. 

The  instruments  necessary  for  the  operation  of  trachel- 
orrhaphy are  two  double  tenacula,  two  sin- 
1         ^^  gle  tenacula,  tissue-forceps,  needle-holder, 

shot-compressor,  Sims'  speculum,  needles, 
(Fig.  102),  knife,  and  scissors,  sharp-pointed 
and  curved  on  the  flat  (Fig.  103).  The 
needles  should  be  spear-pointed  and  should 
be  strong  and  sharp,  as  the  cervical  tis- 
^     .       sues  through  which  they  are  passed  are 

Fig.  102. — Cervix-  ='  t^-,  •    , 

needles.  often  very  dense.       The  straight  or   the 

curved  needle  may  be  used. 
Silkworm  gut,  shotted,  is  an  exceedingly  good  suture- 
material. 


LACERATION  OF  THE  CERVIX  UTERI.  155 

The  woman  should  be  placed  either  in  the  Sims  or  the 
dorso-sacral  position.  The  vulva,  vagina,  and  cervix 
should  be  thoroughly  cleansed  and  rendered  as  aseptic  as 
possible.  The  cervix  should  be  exposed  through  the 
Sims  speculum.     The  anterior  and,  if  desirable,  the  pos- 


FlG.  103. — Curved  scissors  for  performing  trachelorrhaphy. 

terior  lip  of  the  cervix  should  be  seized  with  a  double 
tenaculum  and  held  by  an  assistant;  or  the  lip  may  be 
transfixed  by  a  silk  ligature,  with  which  the  cervix  may 
be  held. 

The  denudation,  which  may  be  made  with  a  knife  or 
with  scissors  curved  on  the  flat,  should  be  begun  upon  the 
lower  lip.  The  tissue  to  be  removed  may  first  be  marked 
out  with  the  knife.  The  tissue  to  either  side  of  the  old 
external  os  is  seized  with  a  tenaculum  or  with  toothed 
tissue-forceps,  and  a  strip  is  elevated  by  an  incision 
extending  into  the  angle  of  the  tear.  A  correspond- 
ing opposite  portion  of  tissue  on  the  anterior  lip  is  then 
seized  in  a  similar  manner,  and  a  similar  strip  of  tis- 
sue is  excised,  meeting  and  joining  the  strip  first  raised 
in  the  angle  of  the  tear.  We  thus  remove  a  wedge- 
shaped  portion  of  tissue.  The  operation  is  then  repeated 
upon  the  other  side.  The  strip  of  mucous  membrane 
that  is  left  on  the  center  of  the  lips  to  form  the  new 
cervical  canal  should  be  about  a  quarter  of  an  inch  in 
width. 

If  the  finger  be  passed  over  the  freshened  surfaces, 
small  indurated  masses  of  tissue  are  sometimes  felt. 
Such  tissue  should  be  caught  with  the  tenaculum  or  the 


156      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

forceps  and  excised.  This  condition  is  most  usual  when 
the  tear  has  been  of  long  standing  and  the  cervix  has 
undergone  sclerotic  changes.  It  is  important  that  the 
excision  of  tissue  should  be  carried  well  up  in  the  angle 
of  the  laceration,  in  order  that  all  hard  cicatricial  tissue 
may  be  excised. 

The  excision  of  tissue  should  be  done  as  nearly  as  pos- 
sible in  the  plane  of  the  laceration.  A  frequent  mistake 
is  to  remove  too  much  tissue  from  the  vaginal  aspect  of 
the  cervix. 

There  is  usually  but  little  bleeding  in  the  operation  of 
trachelorrhaphy,  and  whatever  bleeding  there  is  may 
always  be  controlled  by  properly  placed  sutures. 

The  first  suture  should  embrace  the  angle  of  the  lace- 
ration. It  should  be  introduced  on  the  vaginal  aspect  of 
the  cervix,  near  the  edge  of  the  mucous  membrane,  and 
should  emerge  on  the  edge  of  the  mucous  membrane  of 
the  cervical  canal.  It  should  then  be  reintroduced  at  a 
corresponding  point  on  the  opposite  lip,  and  should 
emerge  on  the  mucous  membrane  of  the  vaginal  aspect. 
It  is  often  difficult  to  bring  the  first  suture  out  on  the 
mucous  membrane  of  the  cervical  canal.  This,  however, 
is  not  necessary  if  the  suture  embraces  the  whole  of  the 
denuded  angle. 

The  other  sutures,  usually  two  or  three  in  number,  are 
introduced  in  a  similar  manner  near  the  edge  of  the 
mucous  membrane  of  the  vaginal  aspect,  pass  around 
the  whole  of  the  denuded  surface,  and  emerge  on  the 
mucous  membrane  of  the  cervical  canal,  near  the  edge. 
They  are  then  re-introduced  on  the  opposite  lip,  and 
emerge  at  a  corresponding  point  on  the  vaginal  aspect  of 
this  lip. 

A  frequent  mistake  is  to  bring  the  sutures  out  on  the 
raw  surface  so  that  the  lateral  union  of  the  torn  lips  is 
shallow  and  superficial,  often  consisting  only  of  the  thick- 
ness of  the  mucous  membrane  of  the  vaginal  aspect  of 
the  cervix.  As  the  result  of  such  an  operation  the  new- 
formed  cervical   canal  is  spindle-shaped,   much  broader 


LACERATION  OF  THE  CERVIX  UTERI.  157 


Fig.  104. — Steps  of  the  operation  of  trachelorrhaphy  for  bilateral  laceration 
of  the  cervix  uteri :  A,  bilateral  laceration  with  erosion ;  B,  the  area  to  be  de- 
nuded has  been  marked  out  with  the  knife ;  C,  the  denudation  has  been  accom- 
plished ;  D,  sutures  introduced ;  E,  completed  operation. 


158      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

than  normal,  and  the  condition  of  an  incomplete  lacera- 
tion of  the  cervix  results. 

After  the  operation  the  vagina  should  be  washed  out 
with  a  I  :  2000  solution  of  bichloride;  it  should  then  be 
dried  with  sponge  or  gauze,  and  a  light  vaginal  pack 
of  sterile  gauze  should  be  introduced. 

The  gauze  pack  should  be  removed  at  the  end  of  forty- 
eight  hours,  and  after  this  a  daily  douche,  with  subse- 
quent drying  of  the  vagina,  should  be  administered. 
The  woman  should  remain  in  bed  for  two  weeks.  There 
is  always  present  some  subinvolution  of  the  uterus,  which 
is  much  benefited  by  rest  in  the  recumbent  position. 

The  sutures  may  be  removed  at  any  time  after  two 
weeks.  To  do  this  the  woman  should  be  placed  in  the 
lithotomy  position.  The  perineum  should  be  retracted 
with  a  Sims  speculum,  and  the  anterior  vaginal  wall 
should  be  supported  by  an  elevator  in  the  hand  of  an  as- 
sistant. 

If  a  perineorrhaphy  is  necessar}-,  it  should  be  performed 
at  the  same  time  as  the  trachelorrhaphy.  In  this  case  the 
cervix  sutures  should  not  be  removed  for  three  or  four 
weeks,  in  order  to  avoid  pressure  upon  the  perineum  by 
the  retracting  speculum. 

If  there  is  present  marked  subinvolution  of  the  uterus 
with  accompanying  endometritis,  the  cervical  canal 
should  be  slightly  dilated  and  the  body  of  the  uterus 
should  be  thoroughly  curetted  immediately  before  per- 
forming the  trachelorrhaphy. 

If  the  operation  of  trachelorrhaphy  is  performed  within 
a  few  months  after  the  receipt  of  the  laceration — before 
sclerotic,  cystic,  and  erosion  changes  have  appeared — 
there  is  usually  required  but  little  preparatory  treatment. 
When,  however,  there  is  a  marked  and  widespread  erosion, 
and  the  cervix  is  full  of  numerous  Nabothian  C5'sts,  or  is 
hard  and  sclerotic  from  inflammatory  exudate,  it  is  neces- 
sary to  devote  from  two  to  six  weeks  to  preparation  of 
the  cervix  for  operation.  Many  failures  in  the  operation 
of  trachelorrhaphy  are  due  to  neglect  of  such  preparatory 


LACERATION  OF  THE  CERVIX  UTERI. 


159 


treatment.  The  hard,  cystic  cervix  may  unite  but  im- 
perfectly after  operation,  or  the  symptoms  referable  to 
the  diseased  cervix  may  remain  unrelieved  by  the  opera- 
tion. We  often  see  women  in  whom  laceration  of  the 
cervix  has  been  closed  with  good  union,  and  yet  the  scle- 
rotic cystic  condition  of  the  cervix,  and  perhaps  subin- 
volution of  the  uterus,  persist,  and  symptoms  comtinue 
as  pronounced  as  before  operation. 

The  preliminary  or  preparatory  treatment  consists  of 
the  administration  of  vaginal  douches,  regulation  of  the 
bowels  by  saline  purgatives,  and  local  applications  to, 
and  puncture  of,  the  cervix  uteri. 

The  woman  should  take,  two  or  three  times  a  day,  a 
vaginal  douche  of  one  gallon  of  hot  water  (110°  F.). 
The  douche  should  be  administered  in  the  recumbent 
posture. 

One  or  two  watery  fecal  movements  should  be  pro- 
duced daily  by  Rochelle  salts,  sul- 
phate of  magnesium,  or  some  sim- 
ilar preparation. 

Every  five  or  six  days  the  woman 
should  be  placed  in  the  knee-chest 
position  and  the  cervix  should  be 
exposed  with  the  Sims  speculum. 
The  Nabothian  cysts,  which  ap- 
pear as  translucent  vesicles  be- 
neath the  mucous  membrane, 
should  each  be  punctured  with 
a  sharp  knife-point.  If  the  cer- 
vix is  much  enlarged  and  con- 
gested, it  should  be  freely  punc- 
tured over  the  whole  vaginal  aspect 
to  produce  local  depletion.  Half 
an  ounce  or  an  ounce  of  blood  may 
be  removed  in  this  way.  The  cer- 
vix    should     then     be    thoroughly 

dried,  and  an  application  of  Churchill's  tincture  of  iodine 
should  be  made  over  the  whole  of  the  cervix  and  the  vagi- 


FiG.  105. — Cotton  tampon. 


ibo       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

nal  vault.  The  excess  of  iodine  should  be  removed  with 
a  little  cotton,  and  a  cotton  tampon  (to  which  is  attached 
a  string)  saturated  with  glycerin  should  be  placed  against 
the  cervix  (Fig.  105).  The  hygroscopic  action  of  the  gly- 
cerin is  most  useful  in  depleting  the  cervix.  The  woman 
should  be  told  to  remove  the  tampon  by  traction  on  the 
strings  at  the  end  of  twelve  hours,  and  to  follow  the  re- 
moval with  a  vaginal  douche  of  hot  water. 

Such  local  treatment  should  be  instituted  immediately 
after  a  menstrual  period  and  should  be  repeated  every  five 
or  six  days,  and  continued  until  the  erosion  and  the  cysts 
have  disappeared  and  the  induration  has  diminished. 
Three  weeks  of  such  treatment  usually  produce  a  very 
marked  change.  The  cervix  not  only  becomes  much 
more  healthy  in  appearance,  but  most  of  the  symptoms 
of  which  the  woman  complained  vanish.  The  leucorrhea 
diminishes  or  ceases;  the  backache  and  headache  dis- 
appear. The  relief  is  often  so  marked  that  the  patient 
suggests  the  advisability  of  deferring  operation.  This, 
however,  should  never  be  countenanced,  as  all  the  symp- 
toms will  return  with  cessation  of  treatment. 

If,  after  the  careful  administration  of  the  treatment 
here  prescribed  for  five  or  six  weeks,  the  induration  and 
cystic  degeneration  do  not  disappear,  then  the  case  is  not 
one  that  will  be  benefited  by  trachelorrhaphy.  The  mere 
closure  or  union  of  the  indurated  and  cystic  lips  of  the 
cervix  will  not  cure  the  woman  if  these  conditions  persist. 

If  the  inflammatory  changes  secondary  to  the  laceration 
have  become  so  deeply  seated  that  they  are  not  relieved 
by  the  preparatory  treatment,  amputation  of  the  cervix 
is  necessary.  In  any  doubtful  case,  therefore,  this  pre- 
paratory treatment  is  to  a  certain  extent  indicative  of  the 
character  of  the  ultimate  operation  to  be  performed. 

The  description  of  the  operation  already  given  is 
applicable  to  the  most  usual  form  of  laceration — a  bi- 
lateral laceration.  If  the  injury  be  unilateral,  it  may  be 
necessary  to  split  the  cervix  on  the  sound  side  in  order  to 
denude,  and  to  introduce  sutures,  on  the  injured  side.   The 


LACERATION  OF  THE  CERVIX  UTERI. 


i6r 


case  may  then  be  repaired  as  in  the  bilateral  form  of 
injury.  In  the  case  of  the  unusual  stellate  laceration  the 
lacerations  must  be  separately  repaired,  or  two  lacerations 
may  be  converted  into  one  by  excision  of  the  intervening 
tissue. 

The  incomplete  laceration  may  be  recognized  in  the 
manner  already  described,  by  introducing  a  sound  into 
the  cervical  canal  and  a  finger  in  the  vaginal  fornix. 
Such  an  injury  should  be  treated  by  splitting  up  the 
cervix  and  converting  the  incomplete  into  a  complete 
tear,  and  then  denuding  where  necessary  and  closing  as 
in  the  case  of  an  open  laceration. 

If,  in  an  old  laceration,  the  sclerotic  and  cystic  condi- 
tion of  the  cervix  does  not 
yield  to  the  preparatory  treat- 
ment advised,  amputation  of 
the  cervix  is  necessary. 

Amputation  of  the  Cer- 
vix.— This  operation  is  per- 
formed as  follows:  The  cer- 
vix is  split  bilaterally  to  the 
vaginal  junction  with  knife 
or  scissors.  Two  flaps  are 
formed  in  this  wa}^,  and  each 
flap  is  then  amputated  sepa- 
rately, the  posterior  one  first 
(Figs.  107-109).  An  incision 
is  made  on  the  vaginal  aspect 
of  the  posterior  flap,  extend- 
ing from  the  angle  of  the 
split  on  one  side  to  the  angle 
of  that  on  the  other.  The 
knife  is  thrust  deeply  into 
the  cervical  tissue  and  is 
directed  toward  the  cervical 

canal.    An  incision  is  then  made  across  the  mucous  mem- 
brane of  the  cervical  canal,  on  the  anterior  aspect  of  this 
flap.     The  posterior  lip  is  thus  removed.     The  anterior 
11 


Fig.  106. — An  old  incomplete 
laceration  of  the  cervix  with  hyper- 
trophy and  cystic  degeneration.  Am- 
putation is  necessary. 


l63      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

A  B 


Fig.  107.— Operation  of  amputation  of  the  cervix  uteri  :  A,  the  cervix  has  been  split  laterally, 

forming  an  anterior  and  a  posterior  flap ;  B,  the  posterior  flap  has  been  partly  amputated. 

A  B 


Fig.  108. — A,  the  posterior  flap  has  been  amputated ;  B,  both  flaps  have  been  amputated. 


LACERATION  OF  THE  CERVIX  UTERI. 


163 


lip  is  removed  in  a  similar  manner.  The  stump  of  the 
cervix  is  then  closed  by  sutures.  Two  or  three  sutures 
are  introduced  on  each  side  of  the  cervix  to  close  the 
angles,  just  as  in  the  operation  of  trachelorrhaphy  for  a 
bilateral  tear,  and  two  sutures  are  introduced  on  each  flap 
to  attach  the  mucous  membrane  of  the  cervical  canal  to 
the  mucous  membrane  of  the  vaginal  aspect,  to  form  the 
new  external  os.  The  first  sutures  should  be  passed  well 
A  n 


Fig.  109. — A,  the  sutures  have  been  introduced ;  B,  completed  operation. 

up  in  the  angles  at  the  lateral  vaginal  fornices,  to  control 
bleeding.  Bleeding  is  more  likely  to  be  free  in  this  ope- 
ration than  in  a  simple  trachelorrhaphy,  but  it  may  al- 
ways be  controlled  by  the  proper  application  of  the  first 
sutures  placed  in  the  angles. 

The  post-operative  treatment  is  similar  to  that  after  the 
operation  of  trachelorrhaphy. 

Amputation  of  the  cervix  does  not  interfere  with  con- 
ception, with  the  course  of  pregnancy,  or  with  labor. 


CHAPTER    XIIL 

INFLAMMATION   OF  THE   CERVICAL  MUCOUS  MEM= 
BRANE   (CERVICAL  CATARRH). 

The  mucous  membrane  of  the  cervical  canal  may  be 
the  seat  of  acute  or  chronic  inflammation.  Acute  inflam- 
mation usually  occurs  as  part  of  a  general  acute  process 
affecting  the  whole  of  the  endometrium,  and  is  com- 
monly the  result  of  gonorrheal  or  septic  infection.  It 
will  be  considered  under  General  Endometritis. 

Chronic  inflammation  of  the  mucous  membrane  of  the 
cervical  canal  (cervical  catarrh  or  cervical  endometritis) 
is  an  exceedingly  common  affection.  Unless  caused  by 
gonorrhea,  it  is  nearly  always  secondary  to  some  local  or 
general  condition. 

The  pathological  changes  that  take  place  in  the  mu- 
cous membrane  resemble  those  found  in  a  similar  pro- 
cess in  other  parts  of  the  body.  There  is  a  very  marked 
congestion  and  hypersecretion  of  the  racemose  glands 
of  the  cervical  canal,  so  that  the  most  prominent  symp- 
tom of  cervical  catarrh,  a  profuse  cervical  leucorrhea,  is 
produced.  This  discharge  resembles  the  normal  secre- 
tion of  the  cervical  glands.  In  its  physical  properties  it 
is  characteristic.  It  is  a  thick,  tenacious  mucus,  and 
differs  decidedly  from  the  thin,  more  serous  discharge 
from  the  vagina  or  from  the  body  of  the  uterus.  The 
discharge  is  often  opaque  ;  it  is  rarely  purulent,  and  is 
very  rarely  streaked  with  blood.  The  mucous  membrane 
of  the  cervical  canal  becomes  swollen,  and  may  project  or 
prolapse  beyond  the  limits  of  the  external  os,  so  that  the 
external  os  has  around  it  a  ring  of  red  congested  mu- 
cous membrane.     A  similar  condition  is  observed  on  the 

164 


CERVICAL  CATARRH.  165 

eyelids  in  conjunctivitis.  Such  a  prolapse  of  the  mucous 
membrane  would  bring  the  orifices  of  some  of  the  race- 
mose glands  upon  the  vaginal  aspect  of  the  cervix,  where 
it  will  be  remembered  they  are  not  normally  present. 
The  inflammatory  action  extends  beyond  the  limits  of  the 
external  os  on  to  the  vaginal  aspect  of  the  cervix.  The 
squamous  epithelium  exfoliates  over  a  limited  area  around 
the  external  os,  and  there  is  produced  an  erosion  resem- 
bling that  already  described  under  Laceration  of  the  Cer- 
vix. Consequently,  the  red  eroded  area  surrounding  the 
external  os  that  appears  in  many  cases  of  chronic  inflam- 
mation of  the  cervical  mucous  membrane  is  due  to  ex- 
tension of  the  inflammatory  process  on  to  the  vaginal 
aspect  (with  desquamation  of  the  superficial  squamous 
cells)  and  to  prolapse  of  the  mucous  membrane  of  the 
cervical  canal.  The  racemose  glands  may  become  ob- 
structed, either  as  a  result  of  thickening  in  the  character 
of  the  secretion  or  of  occlusion  of  the  orifices,  and  small 
retention-cysts  are  formed,  which  often  fill  the  body  of 
the  cervix,  and,  extending  peripherally,  appear  beneath 
the  mucous  membrane  of  the  vaginal  aspect.  The  cer- 
vix is  then  said  to  have  undergone  cystic  degeneration. 
Deep-seated  inflammatory  changes  may  also  take  place 
as  a  result  of  cervical  catarrh,  so  that  at  first  a  slight 
hypertrophy  from  inflammatory  exudate  results,  and  later 
the  formation  of  connective  tissue  produces  a  sclerotic 
condition  of  the  cervix. 

As  has  been  said,  chronic  cervical  catarrh,  unless  of 
gonorrheal  origin,  is  nearly  always  secondary  to  some 
local  or  general  condition.  The  most  usual  cause  of  the 
disease  is  laceration  of  the  cervix,  which  causes  inflam- 
mation of  the  mucous  membrane  by  direct  injury  and 
exposure. 

The  various  flexions  and  displacements  of  the  uterus 
are  often  accompanied  by  cervical  catarrh,  which  proba- 
bly is  caused  by  the  chronic  congestion  brought  about  by 
interference  with  the  circulation  of  the  body  and  cervix. 
The  use  of  frequent  douches  of  cold  water  to  prevent 


1 66      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

conception  is  said  to  result  in  chronic  inflammation  of 
the  cervical  mucous  membrane. 

Imperfect  involution  after  labor,  miscarriage,  or  men- 
struation may  cause  cervical  catarrh  from  the  chronic 
congestion  that  results. 

Gonorrhea  seems  in  many  cases  to  be  communicated 
directly  and  primarily  to  the  cervical  mucous  membrane, 
and  results  in  a  most  obstinate  form  of  chronic  inflam- 
mation. 

The  scrofulous  and  tubercular  diatheses  seem  undoubt- 
edly to  predispose  a  woman  to  chronic  inflammation  of 
the  mucous  membrane  of  the  cervix,  as  of  other  mucous 
membranes  of  the  body.  Cervical  catarrh  often  appears 
in  such  women  without  any  local  lesion  to  account  for  it. 
The  severity  of  the  local  trouble  depends  upon  the  gen- 
eral condition,  diminishing  when  the  general  health  im- 
proves. 

In  all  cases  of  cervical  catarrh,  even  though  dependent 
upon  a  distinct  local  lesion  like  a  laceration  of  the  cervix 
or  a  flexion  of  the  uterus,  the  severity  of  the  catarrh,  as 
measured  by  the  quantity  of  the  discharge,  is  very  much 
dependent  upon  the  general  health.  The  woman  is  often 
troubled  by  leucorrhea  only  at  those  times  at  which  her 
general  health  is  impaired  by  overwork,  anxiety,  or  from 
some  other  cause;  and  even  though  the  disease  may  be 
apparently  cured  by  appropriate  treatment,  the  symptom, 
leucorrhea,  is  very  apt  to  reappear  whenever  the  woman 
is  subjected  to  such  depressing  influences. 

The  most  conspicuous  symptom  of  cervical  catarrh  is 
the  leucorrhea — the  discharge  from  the  cervical  glands. 
As  has  already  been  said,  in  its  physical  properties  it  is 
characteristic.  It  is  a  thick,  opaque,  tenacious  mucus. 
The  quantity  is  often  so  great  that  the  clothes  of  the 
woman  are  soiled  and  she  is  obliged  to  wear  a  napkin. 

There  may  be  present  slight  backache  and  a  feeling  of 
vague  discomfort  or  pain  in  the  pelvis  as  a  result  of  the 
inflammation  of  the  cervix.  It  is  difficult,  however,  to 
separate   symptoms   referable   distinctly  to   the    cervical 


CERVICAL  CATARRH.  167 

inflammation  from  those  due  to  the  primary  trouble,  to 
which  the  cervical  inflammation  is  also  to  be  attributed. 
The  only  one  distinct  symptom  of  cervical  inflammation 
is  the  leucorrhea. 

Digital  examination  in  a  case  of  cervical  catarrh  usually 
reveals  an  altered  condition  of  the  cervix.  The  vaginal 
cervix  may  be  somewhat  enlarged  and  soft  in  the  early 
stages  of  the  disease,  or  cystic  and  sclerotic  in  the  later 
stages.  The  external  os  is  usually  enlarged,  often  admit- 
ting the  tip  of  the  index  finger  even  in  those  who  have  not 
suffered  with  laceration  of  the  cervix.  The  prolapsed 
mucous  membrane  is  present,  and  the  erosion  may  be 
readily  felt  around  the  external  os,  being  easily  distin- 
guished from  the  smooth,  less  velvety  squamous  mucous 
membrane  of  the  vaginal  aspect. 

Speculum  examination  shows  a  congested  vaginal  cer- 
vix and  a  patulous  external  os  around  which  is  the  red 
erosion  already  described.  Escaping  from  the  external 
OS  is  seen  the  thick  cervical  mucus,  which  is  often  so 
tenacious  that  it  may  be  lifted  from  the  cervical  canal 
with  forceps. 

The  diagnosis  of  cervical  catarrh  is  usually  very  easily 
made  from  a  consideration  of  the  signs  described.  The 
important  thing  in  any  case  is  to  determine  the  cause  of 
the  inflammation  of  the  cervical  mucous  membrane,  in 
order  that  the  proper  treatment  may  be   directed  to  it. 

Treatment. — As  has  been  said,  cervical  catarrh  is 
always  secondary  to  some  local  or  general  condition, 
except  in  the  case  of  direct  gonorrheal  infection.  The 
gonorrheal  cases  must  be  determined  by  the  history  of 
the  disease  and  by  the  distinctive  signs  of  gonorrheal 
infection  which  will  be  described  later. 

In  every  case  of  cervical  catarrh  a  thorough  examina- 
tion to  determine  the  local  cause  of  the  disorder  must  be 
made.  If,  as  will  usually  be  the  case,  such  a  local  cause 
is  discovered,  the  treatment  should  be  applied  to  it,  and 
the  inflammation  of  the  mucous  membrane  may  be  dis- 
regarded, with  confidence  that  it  will  disappear  when  the 


1 68       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

exciting  cause  is  removed.  Many  cases  are  treated  by 
local  applications,  the  whole  attention  of  the  physician 
being  wrongly  directed  to  the  secondary  condition,  while 
the  exciting  lesion,  such  as  laceration  of  the  cervix,  sub- 
involution, or  a  flexion  or  version,  is  neglected.  Such 
treatment,  of  course,  results  in  but  temporary  benefit. 

Besides  such  cases  of  chronic  local  inflammation  depend- 
ent upon  a  distinct  local  lesion,  there  are  many  others 
in  which  the  catarrh  is  but  a  local  manifestation  of  a 
general  state  of  depressed  or  poor  health,  or  of  a  distinct 
dyscrasia  like  tuberculosis,  syphilis,  or  scrofula.  Local 
treatment  in  such  cases,  to  the  neglect  of  the  general 
health,   is  wrong. 

If  the  advice  here  given — to  seek  for  the  primary  cause 
of  the  cervical  catarrh  and  to  cure  it — is  followed,  it  will 
be  found  that  there  are  but  very  few  cases  that  depend 
for  cure  upon  local  applications.  Simple  local  treatment 
by  douches,  etc.  may,  however,  be  valuable  aids  in 
hastening  the  cure  of  the  disease  after  the  exciting  cause 
has  been  removed. 

The  treatment  may  be  considered  under  two  heads,  the 
general  and  the  local  treatment. 

General  tonic  treatment  is  required  in  most  cases  of 
protracted  cervical  catarrh.  The  preparations  of  iron 
are  the  most  valuable  in  this  condition. 

The  contraindication  to  the  use  of  iron  in  uterine  dis- 
ease is  menorrhagia  or  metrorrhagia — profuse  bleeding 
from  the  uterus.  If  in  any  case  this  symptom  is  present, 
and  it  is  found  that  the  bleeding  is  increased  after  the 
administration  of  iron,  then  this  drug  should  be  discon- 
tinued. 

The  following  are  useful  prescriptions  in  those  cases  in 
which  iron  is  indicated: 

Bland's  pill,  the  prescription  for  which  may  be  written: 
I^.   Pulv.  ferri  sulph.  exsic. 

Potass,  carb.  purse,  aa.  sij. 

Ut  fiat,  massa  dividenda  in  pilulas  No.  xlviii. 
Sig.   One  pill  three  or  four  times  a  day. 


CERVICAL  CATARRH.  169 

Basham's  mixture,  the  formula  for  which  is — 

I^.   Tinct.  ferri  chloridi,  f^iss; 

Acidi  acetici  diluti,  f.^ij ; 

Liquor,  ammonise  acetat. ,  fSxiv; 

Elix.  aurantii,  f3vj; 

Glycerin.,  f§j; 

Aquae,  f^iv. 
M.   Sig.  Tablespoonful  after  each  meal. 

The  prescription  which  Professor  Goodell  called   the 
"mixture  of  the  four  chlorides"  is — 


^.   Hydrarg.  chloridi  corrosivi, 

gr-  j-ij; 

Iviq.  arsenici  chloridi, 

gtt  xlviij; 

Tinct.  ferri  chloridi, 

Acidi  hydrochlorici  dil., 

aa.  fsiv; 

Syrupi, 

Oiij; 

Aquae, 

ad  f  Ivj. 

M.   Sig.  One  dessertspoonful 

in  a  wineglassful  of 

water  after  meals. 

This  prescription  should  not  be  given  for  more  than 
•two  weeks  at  a  time. 

Careful  attention  should  always  be  paid  to  the  regu- 
larity of  the  bowels,  in  order  to  prevent  pelvic  conges- 
tion, which  may  result  from  constipation. 

Two  or  three  drams  of  Rochelle  salts  may  be  adminis- 
tered in  a  tumblerful  of  water  every  morning,  one  hour 
before  breakfast. 

A  useful  prescription,  combining  the  saline  purgative 
;and  the  iron,   is — 


^.   Ferri  sulph.. 

gr-  xij; 

Magnes.  sulph., 

iiss; 

Sodii  chloridi, 

gr.  xij; 

Acid,  sulph.  dil., 

3iss; 

Infus.  quassiae. 

ad 

,lvj. 

,M.   Sig.   One  tablespoonful  one  hour  before  meals. 


170       A   TEXT- BOOK  OF  DISEASES  OF  WOMEN. 

An  excellent  laxative  pill  is — 

!^.   Extract,  colocynthidis, 

Extract,  hyoscyami,  da.   gr.  x; 

Massae  hydrargyri,  gr.  xx. 

M.   Fiat  massa  dividenda  in  pilulas  No.  xx. 
Sig.   One  pill  three  times  a  day. 

Strychnine  in  addition  to  the  iron  is  often  a  most  use- 
ful medicine  in  this  condition  of  cervical  catarrh. 

Various  medicines  have  been  administered  internally 
to  control  the  hypersecretion  from  the  cervical  glands. 
Such  therapeutics,  however,  is  not  to  be  relied  upon. 

Any  distinct  pathological  condition,  like  tuberculosis 
or  syphilis,  should,  of  course,  receive  the  appropriate 
treatment. 

Local  treatment  may  be  directed  to  the  vaginal  aspect 
of  the  cervix  or  directly  to  the  cervical  canal.  The 
former  treatment  should  always  be  tried  first,  and  it  will 
usually  be  found  sufficient.  It  consists  of  the  administra- 
tion of  hot  vaginal  douches,  the  application  of  Churchill's 
tincture  of  iodine  to  the  vaginal  vault,  and  the  use  of  the 
glycerin  tampon  as  described  under  the  treatment  of 
laceration  of  the  cervix.  Puncture  of  the  cervix  in  order 
to  produce  local  depletion,  as  already  mentioned  in  the 
preparatory  treatment  of  laceration  of  the  cervix,  may 
also  be  tried. 

If  any  case  of  cervical  catarrh  persists  after  the  cure 
of  the  primary  local  or  general  lesion,  in  case  such  a 
lesion  is  present,  and  after  the  additional  local  treatment 
by  douches  and  applications  to  the  vaginal  vault,  then 
we  may  be  obliged  to  make  applications  directly  to  the 
mucous  membrane  of  the  cervical  canal. 

These  applications  should  be  made  as  follows,  any  time 
in  the  menstrual  interval  being  appropriate:  The  cervix 
should  be  exposed  through  the  Sims  or  the  bivalve  spec- 
ulum, and  should  be  steadied  by  seizing  it  with  a  tenac- 
ulum. The  cervical  canal  should  then  be  wiped  out 
with  cotton  either  in  the  grasp  of  long  thin  forceps  or 


CERVICAL    CATARRH.  1 71 

upon  an  applicator.  The  cervical  mucus  should  be  re- 
moved in  this  way,  in  order  to  permit  the  direct  applica- 
tion of  the  desired  solution  to  the  mucous  membrane. 
The  applicator  or  forceps,  armed  with  cotton  saturated  with 
the  solution,  should  be  introduced  in  the  cervical  canal 
and  applied  to  all  portions  of  the  mucous  membrane. 

In  place  of  the  applicator  we  may  use  the  glass  pipette 
or  instillation-tube  (Fig.  no),  as  recommended  by  Skene. 


Fig.  1 10. — Instillation-tube. 

This  instrument,  charged  with  a  few  drops  of  the  solu- 
tion, should  be  introduced  as  far  as  the  internal  os,  and 
the  solution  should  be  expressed  as  the  pipette  is  slowly 
withdrawn. 

In  most  cases  of  cervical  catarrh  the  external  os  is  suf- 
ficiently large  and  the  canal  sufficiently  patulous  to  per- 
mit the  applications  already  described.  Sometimes,  how- 
ever, when  the  external  os  and  the  canal  are  contracted, 
it  is  desirable  to  dilate  slightly  with  the  small  uterine 
dilators  before  making  the  application.  Such  dilata- 
tion to  one-quarter  or  one-half  an  inch  may  be  per- 
formed without  an  anesthetic,  and  may  be  repeated  as 
often  as  necessary. 

Various  solutions  are  used  for  application  to  the  cervi- 
cal canal.  Violent  caustics  should  be  avoided.  The 
solutions  of  mild  strength  are  preferable.  A  solution  of 
I  or  2  grains  to  the  ounce  of  chloride  of  zinc,  sulphate 
of  zinc,  tannic  acid,  nitrate  of  silver,  or  bichloride  of 
mercury  is  often  useful.  An  application  of  pure  carbolic 
acid  is  sometimes  followed  by  good  results.  Perhaps  the 
most  generally  useful  application  is  Churchill's  tincture 
of  iodine  or  a  solution  of  2  parts  of  tincture  of  iodine 
and  I  part  of  carbolic  acid. 


CHAPTER   XIV. 
CONGENITAL  EROSION  AND  SPLIT  OF  THE  CERVIX. 

In  describing  the  lesions  of  laceration  of  the  cervix  and 
cervical  catarrh,  frequent  mention  has  been  made  of  the 
cervical  erosion  or  the  catarrhal  patch.  The  erosion, 
or  red  granular  area,  surrounding  the  external  os  seems 
to  be  caused  by  various  factors.  In  laceration  it  is  due 
to  the  eversion  and  exposure  of  the  normal  cervical 
mucous  membrane,  and  perhaps  to  slight  proliferation 
of  the  cylindrical  cells  of  this  mucous  membrane  on 
to  the  mucous  membrane  of  the  vaginal  aspect  of  the 
cervix.  In  cervical  catarrh  it  is  caused  by  swelling 
and  prolapse  of  the  mucous  membrane  of  the  cervical 
canal,  and  extension  of  the  inflammatory  process  beyond 
the  limits  of  the  external  os,  with  partial  desquamation 
of  the  squamous  cells. 

There  are  other  cases,  however,  in  which  the  erosion 
appears  to  be  congenital.  Such  erosions  have  been  ob- 
served by  Fischel  and  other  investigators  surrounding  the 
external  os  in  new-born  infants.  Erosion  of  this  cha- 
racter has  been  found,  in  a  more  or  less  marked  degree, 
in  36  per  cent,  of  new-born  infants.  Microscopically, 
these  erosions  appear  to  be  a  direct  continuation  of  the 
mucous  membrane  of  the  cervical  canal.  They  are 
covered  with  a  single  layer  of  cylindrical  epithelium, 
and  they  possess  mucous  glands,  resembling  in  these 
features  the  cervical  mucous  membrane,  and  not  the 
mucous  membrane  of  the  vaginal  aspect  of  the  cervix, 
which,  it  will  be  remembered,  is  covered  with  squamous 
epithelium  and  contains  no  glands.  This  congenital 
erosion  usually  is  of  very  limited  extent,  but  in  some 
cases  it  covers  the  greater  part  of  the  vaginal  aspect  of 

172 


CONGENITAL  CERVICAL  EROSION. 


173 


the  cervix,  and  may  then  give  rise  to  decided  symp- 
toms. The  condition  is  due  to  imperfect  development  of 
the  external  os.  In  the  well-formed  woman  there  is,  at 
the  external  os,  a  sharp  line  of  demarcation  between  the 
squamous  epithelium  of  the  vaginal  aspect  and  the  cylin- 
drical epithelium  of  the  cervical  canal.  In  the  congenital 
erosion  the  epithelium  of  the  canal  extends  beyond  the 
limits  of  the  external  os,  and  meets  the  squamous  epithe- 
lium at  a  lower  level  than  normal. 

Such  congenital  erosions  usually  give  rise  to  no  trouble, 
though  perhaps  they  predispose  the  woman  to  cervical 
catarrh  as  a  result  of  exposure  of  the  mucous  membrane. 
In  extreme  cases,  however,  in  which  the  cylindrical  epi- 
thelium of  the  cervical  canal  persists  over  the  greater 
part  of  the  vaginal  cervix,  and  in  which  the  glandular 
elements  of  the  canal  are  found  on  the  vaginal  aspect,  a 
distinct  pathological  condition  arises.  The  symptoms  of 
this  condition  resemble  closely  those  of  laceration  of  the 
cervix  with  ectropion.  There  is  backache,  a  feeling  of 
weight  in  the  pelvis,  and  perhaps 
some  ovarian  pain.  In  addition, 
the  woman  complains  of  a  leucor- 
rhea  presenting  the  characteristics 
of  the  cervical  mucus.  Decided 
nervous  and  digestive  disturbances 
may  be  present. 

If  this  condition  of  congenital 
ectropion  exists  along  with  a  lace- 
ration of  the  cervix,  the  diagnosis 
becomes  very  difficult.  If,  how- 
ever, we  can  exclude  the  possibil- 
ity of  a  former  conception,  we  may 
by  careful  study  determine  the  real 
nature  of  the  case. 

Fig.  Ill  represents  the  appear- 
ance  of  the    cervix   in   a   case  of 

marked  congenital  erosion  in  a  virtuous  single  woman 
twenty  years  of  age.     It  will  be  observed  that  the  appear- 


FiG.    III. — Congenital   ero- 
sion of  the  cervix. 


174       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

ance  resembles  somewhat  that  seen  in  a  bilateral  lacera- 
tion of  the  cervix  with  eversion.  The  following  are  the 
points  of  difference: 

In  laceration — 

There  is  a  history  of  previous  pregnancy. 

The  presenting  face  of  the  cervix  is  oval,  with  the  long 
axis  antero-posterior. 

The  angles  of  laceration  may  be  determined,  by  sight 
or  touch,  either  as  more  or  less  well-marked  depressions 
or  as  hard  plugs  in  case  they  are  filled  up  by  scar- 
tissue.  The  mucous  membrane  of  the  cervical  canal  may 
be  made  out  as  a  strip  on  the  anterior  and  posterior  lips, 
from  which  there  extends  laterally  a  more  or  less  well- 
marked  erosion. 

The  vaginal  cervix  is  not  of  the  general  mushroom 
shape  seen  in  the  figure. 

If  microscopic  examination  of  the  cervix  be  made, 
racemose  glands  will  be  found  discharging  only  on  the 
mucous  membrane  of  the  cervical  canal — not  all  over  the 
vaginal  aspect. 

In  the  congenital  ectropion — 

There  may  be  no  history  of  pregnancy. 

The  presenting  face  of  the  cervix  is  approximately 
circular. 

There  is  no  angle  of  laceration  determined  by  sight  or 
touch. 

The  erosion  may  extend  evenly  around  the  external  os, 
and  there  is  no  one  strip  that  corresponds  to  the  exposed 
mucous  membrane  of  the  cervical  canal. 

The  vaginal  cervix  is  mushroom-shaped,  with  a  decided 
stalk. 

Microscopic  examination  reveals  racemose  glands  dis- 
charging over  the  greater  part  of  the  vaginal  cervix,  to  the 
sides  of  the  external  os,  as  well  as  in  front  of  and  behind  it. 

The  ultimate  test  of  this  condition  is  the  discovery  of 
the  glands  discharging  on  the  vaginal  aspect  of  a  cervix 
in  which  the  mucous  membrane  of  the  cervical  canal  had 
not  been  exposed  by  laceration. 


CONGENITAL  CERVICAL  EROSION.  175 

The  treatment  of  congenital  erosion  of  the  cervix, 
when  it  is  so  marked  as  to  produce  distinct  symptoms,  is 
amputation  of  the  cervix. 

Congenital  Split  of  the  Cervix.— There  is  some- 
times found  a  congenital  split  of  the  cervix,  closely  re- 
sembling a  unilateral  or  bilateral  laceration  following 
labor  or  miscarriage.  The  recognition  of  this  fact  is  of 
great  medico-legal  importance.  One  of  the  most  positive 
signs  of  a  former  conception  is  a  laceration  of  the  cervix. 
In  some  cases,  however,  a  condition  resembling  such  a 
laceration  may  exist  from  birth.  Marked  lateral  split  of 
the  cervix  has  been  discovered  in  the  new-born  infant, 
and  several  cases  have  been  observed  in  which  this  con- 
dition has  been  found  in  adults  of  undoubted  virginity. 

It  is  possible  that  this  condition  may  become  patho- 
logical. Cervical  catarrh  might  be  produced  from  expos- 
ure of  the  mucous  membrane  of  the  cervical  canal.  The 
lesion,  however,  is  not  of  nearly  such  serious  moment  as 
a  laceration  after  miscarriage  or  labor,  for  the  last  injury 
occurs  in  a  uterus  which  must  undergo  involution,  and 
the  chief  symptoms  of  laceration  of  the  cervix  are  usu- 
ally those  incident  to  arrested  involution. 


CHAPTER   XV. 

CERVICAL  POLYPI;  HYPERTROPHIC  ELONGATION 
OF  THE  CERVIX;  CHANCRE  OF  THE  CERVIX; 
TUBERCULOSIS    OF    THE    CERVIX. 

Cervical  Polypi. — Polypoid  tumors  are  found  grow- 
ing from  the  mucous  membrane  of  the  cervical  canal, 
projecting  into  the  canal  or  protruding  from  the  external 
OS.  The  mucous  polypus  is  the  most  usual  form,  and  is 
caused  by  cystic  degeneration  of  the  Nabothian  glands 
of  the  cervical  mucous  membrane.  Sometimes  such 
polypi  protrude  from  the  ostium  vaginae.  Less  often 
a  papillary  or  warty  growth  is  found  on  the  mucous 
membrane  of  the  cervical  canal,  in  the  neighborhood  of 
the  external  os.  There  is  usually  present  dilatation  of 
the  external  os  and  cervical  canal.  The  symptoms 
of  cervical  polypi  are  not  characteristic.  Inflammation 
of  the  cervical  mucous  membrane  and  cervical  catarrh 
may  result.  There  may  be  slight,  and  rarely  profuse, 
bleeding  from  the  external  os.  The  bleeding  may  follow 
efforts  at  straining,  sexual  connection,  long  standing,  or 
exercise.  Occurring  at  the  time  of  the  menopause  or 
later,  this  symptom  would  excite  the  suspicion  of  begin- 
ning cancer  of  the  cervix. 

Pediculated  polypi  should  be  twisted  or  cut  away. 
Bleeding  is  usually  very  slight.  The  sessile  growths, 
like  the  papillomata,  should  be  excised,  the  incision  be- 
ing carried  well  below  the  base  of  the  tumor  into  the 
healthy  tissue  of  the  cervix.  The  wound  may  then  be 
closed  with  an  interrupted  suture.  In  every  case  of  such 
tumor  a  careful  microscopical  examination  should  be 
made  to  determine  its  benign  or  malignant  character. 

Hypertrophic  Elongation  of  the  Vaginal  Cervix. 

176 


CERVICAL  POLYPI,  ETC 


177 


— In  this  condition  there  is  a  marked  increase  in  the 
length  of  the  vaginal  portion  of  the  cervix  uteri,  though 
the  thickness  of  the  cervix  ma}^  be  but  little,  if  any, 
greater  than  normal.  The  vaginal  cervix  may  be  so  long 
that  the  external  os  may  lie  outside  the  ostium  vaginse. 


Fig.  113. — Cervical  polyp. 

The  condition  is  a  true  hypertrophic  growth,  the  cause 
of  which  is  unknown.  It  is  probably  congenital,  as  it  is 
found  in  the  virgin. 

The  diagnosis  between  elongation  of  the  vaginal  cervix 
and  the  various  forms  of  prolapse  of  the  uterus  and  the 
12 


178      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

vagina  may  be  readily  made.  In  elongation  of  the  vag- 
inal cervix  the  fundus  uteri  is  at  the  normal  level;  there 
is  no  inversion  of  the  vagina;  the  vaginal  fornices  are  in 
the  normal  position. 

Elongation  of  the  vaginal  cervix  to  a  degree  sufficient 
to  be  considered  pathological  is  very  rare. 

The  treatment  consists  in  amputation  of  the  cervix. 

Chancre  of  the  Cervix. — Chancre  of  the  cervix  is  a 
rare  lesion.  One  observer,  Rassennone,  found  117  uter- 
ine chancres  in  a  series  of  1375  cases  of  venereal  sores  on 
the  female  genitals.  The  sore  may  occur  on  either  lip 
of  the  cervix  and  may  extend  into  the  cervical  canal. 
The  appearance  is  that  characteristic  of  similar  sores  in 
other  parts  of  the  body. 

The  diagnosis  may  be  made  from  a  history  of  coitus 
with  a  man  having  active  syphilis,  by  microscopic  exam- 
ination if  necessary,  and  by  the  later  appearance  of  sec- 
ondary syphilitic  symptoms. 

Tuberculosis  of  the  Cervix. — Tuberculosis  of  the 
cervix  is  a  very  rare  condition.  The  appearance  of  the 
cervix  in  such  cases  resembles  that  of  cancer.  In  fact, 
hysterectomy  has  been  performed  for  this  condition 
under  the  mistaken  diagnosis  of  malignant  disease. 

The  diagnosis  may  be  made  by  the  microscopic  exam- 
ination of  the  discharge  and  of  excised  tissue. 

Complete  hysterectomy  should  be  performed  for  tuber- 
culosis of  the  cervix. 


CHAPTER  XVI. 
CANCER  OF    THE  CERVIX  UTERI. 

Cancer  of  the  cervix  uteri  is  a  very  common  disease. 
About  one-third  of  all  cases  of  cancer  in  women  affect 
the  uterus.  Like  cancer  in  other  parts  of  the  body,  the 
disease  has  been  observed  at  almost  every  period  of  life 
except  infancy.  It  occurs  most  frequently  during  the 
active  mature  life  of  the  woman,  between  the  ages  of 
thirty  and  fifty.  It  is  probable  that  more  cases  occur 
during  the  latter  decade  of  this  period  than  during  the 
former. 

Cancer  of  the  cervix  is  a  disease  of  the  childbearing 
woman.  It  is  very  rare  in  women  who  have  never  con- 
ceived. Statistics  show  that  women  who  develop  cancer 
of  the  cervix  have  borne  on  an  average  five  children. 
The  stout,  well-nourished  mother  of  a  large  family  is 
very  prone  to  cancer  of  the  cervix. 

It  is  probable  that  the  chief  predisposing  cause  of  can- 
cer of  the  cervix  is  a  fissure  or  laceration  caused  by  mis- 
carriage or  labor.  A  focus  of  irritation,  a  point  of  dim- 
inished resistance,  is  thus  developed,  where  cancer  may 
start  in  a  woman  predisposed  to  this  disease.  In  some  of 
the  cases  of  cancer  of  the  cervix  occurring  in  sterile 
women  it  has  been  found  that  previous  traumatism  had 
been  inflicted  by  dilatation  or  incision  of  the  cervix. 

Cancer  of  the  cervix  uteri  originates  in  one  of  three 
structures:  I.  The  squamous  epithelium  covering  the 
vaginal  aspect  of  the  cervix;  II.  The  cylindrical  cells 
lining  the  cervical  canal;  III.  The  epithelial  cells  of  the 
cervical  glands.  The  first  variety  is  called  squamous- 
cell  carcinoma  of  the  cervix.  The  second  and  third 
varieties  are  called  adeno-carcinoma  of  the  cervix. 

179 


i8o      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


The  early  appearance  of  the  disease,  the  gross  form 
assumed  by  the  cancer,  the  direction  of  growth,  and  the 
clinical  course  depend  upon  the  place  of  origin.  In  the 
late  stages  of  the  disease,  characterized  by  extensive  de- 
struction of  tissue,  all  forms  appear  alike. 

I.  Cancer  of  the  vaginal  aspect  of  the  cervix  (squamous- 
cell  carcinoma)  very  often  begins  in  a  benign  erosion  of 
an  old  laceration.  The  early  stages  of  transition  from 
the  benign  to  the  malignant  condition  are  not  apparent 
to  the  unaided  senses,  and  can  be  recognized  only  by  the 
microscope.     Later  a  superficial  ulceration  is  developed, 


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Fig.  1 14. — Cancer  of  the  vaginal  aspect  of  the  cervix. 

or  the  cancer  may  assume  the  polypoid  or  vegetating  form, 
and  become  readily  recognized  by  the  unaided  senses. 

It  will  be  remembered  that  true  ulceration  as  a  benign 
condition  is  very  rare  on  the  cervix  uteri.  The  erosion 
of  a  laceration  is  in  no  sense  an  ulceration.  An  ulcera- 
tion of  the  cervix,  therefore,  should  always  excite  the 
gravest  suspicion.  The  polypoid  or  vegetating  growths 
vary  very  much  in  size.     They  are  sometimes  very  exu- 


CANCER  OF  THE  CERVIX  UTERI. 


i8i 


berant,  forming-  large  cauliflower-like  masses  filling  the 
upper  part  of  the  vagina  (Fig.  114).  In  other  cases  they 
are  small  warty  growths  or  rounded  protuberances  about 
the  size  of  a  pea.  The  disease  usually  spreads  to  the 
mucous  membrane  of  the  vagina.  Less  often  it  extends 
to  the  cervical  canal  and  to  the  body  of  the  uterus. 

II.  When  the  cancer  begins  in  the  mucous  membrane 
of  the  cervical  canal  (adeno-carcinoma),  extensive  de- 
struction of  tissue  may  take  place  before  any  appearance 


Fig.  115. — Cancer  of  the  cervical  canal,  with  metastasis  to  the  vagina. 

of  the  disease  is  observed  at  the  external  os  (Fig.  115). 
This  is  most  likely  to  occur  in  those  cases  in  which  there 
is  not  present  a  bilateral  laceration  of  the  cervix  with 
eversion  of  the  mucous  membrane.  In  some  cases  the 
whole  of  the  cervix  is  destroyed,  leaving  only  a  shell,  the 
lower  portion  of  which  is  the  vaginal  aspect  of  the  cervix. 
When  the  cervix  is  lacerated  and  the  mucous  mem- 
brane of  the  canal  is  exposed,  the  disease  is  more  early 
apparent,  and  we  may  then  observe  the  malignant  ulcera- 


l82       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

tion  of  the  exposed  mucous  membraue  or  the  presence 
on  it  of  cancerous  outgrowths.  This  form  of  cancer  of 
the  cervix  uteri  is  more  likely  to  extend  upward  to  the 
endometrium  than  is  the  form  first  described. 

III.  When  the  cancer  begins  in  the  distal  ends  of  the 
cervical  glands  (adeno-carcinoma),  it  may  appear  as  a  nod- 
ule in  the  body  of  the  cervix.  It  will  be  remembered  that 
sometimes  these  glands  become  so  distended  peripherally 
that  they  appear  beneath  the  mucous  membrane  of  the  vag- 
inal aspect  of  the  cervix  as  Nabothian  cysts.  In  a  similar 
wav,  when  the  glands  become  seats  of  cancerous  infection, 


Fig.  ii6. — Nodular  cancer  of  the  neck  of  the  uterus  {a)  (Ruge  and  Veit). 

hard  nodules  of  various  size  may  appear  or  be  felt  beneath 
the  vasfinal  mucous  membrane.  In  other  cases  the  nodule 
is  situated  beneath  the  mucous  membrane  of  the  cervical 
canal.  These  nodules  disintegrate  and  perforate  the 
overlying  mucous  membrane,  and  in  this  way  form  a 
malignant  ulcer  which  may  appear  either  in  the  cervical 
canal  or  on  the  vaginal  aspect  of  the  cervix. 

As  has  been  said,  when  ulceration  and  destruction  take 


CANCER  OF  THE  CERVIX  UTERI.  183 

place,  in  the  last  stages  of  the  disease,  all  the  varieties  of 
cancer  present  a  similar  appearance  and  are  accompanied 
by  similar  symptoms. 

Cancer  of  the  cervix  nteri  may  extend  to  the  vagina, 
to  the  body  of  the  uterus,  to  the  broad  ligaments,  the 
bladder,  rectum,  ureters,  and  the  peritoneum,  and  it  may 
be  carried  by  the  lymphatic  vessels  to  the  pelvic  and 
inguinal  lymphatic  glands. 

In  nearly  all  cases  of  long  standing  the  upper  part  of 
the  vagina  is  involved.  Sometimes  the  whole  of  the 
vaginal  canal,  from  the  cervix  to  the  vulva,  is  infiltrated 
with  cancerous  growths. 

The  body  of  the  uterus  always  becomes  involved  sooner 
or  later.  This  is  most  apt  to  occur  in  those  cases  in 
which  the  disease  begins  in  the  cervical  canal.  The 
endometrium  is  affected  by  direct  extension,  the  malig- 
nant disease  being  often  preceded  by  some  benign  form 
of  endometritis. 

Sometimes  the  cervix  becomes  hypertrophied  by  general 
infiltration  to  three  or  four  times  its  usual  size. 

The  broad  ligaments  are  very  usually  involved  by  direct 
extension  of  the  disease.  They  become  thick,  hard,  and 
very  rigid,  holding  the  uterus  fixed  in  the  pelvis.  When 
only  one  ligament  is  affected,  the  uterus  is  drawn  to  that 
side.  The  ureters  become  involved  by  extension  of  the 
infiltration  to  their  walls  or  by  pressure  upon  them  by 
the  thickened  broad  ligaments. 

The  bladder,  on  account  of  its  close  relationship  to  the 
cervix,  is  always  involved  in  the  last  stages.  The  disease 
may  extend  to  the  vesical  mucous  membrane,  and  symp- 
toms of  cystitis  will  appear.  Sometimes  the  vesico-vag- 
inal  septum  is  destroyed  and  a  urinary  fistula  results. 
Extension  to  the  rectum  is  not  so  common.  As  the  dis- 
ease extends  upward  the  peritoneum  may  be  perforated, 
though  this  is  an  unusual  accident.  In  most  cases  peri- 
toneal involvement  is  preceded  by  local  inflammation  and 
by  adhesions  which  prevent  direct  penetration  of  the 
peritoneal  cavity. 


1 84       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  pelvic  and  retroperitoneal  lymphatic  glands  be- 
come affected  in  the  later  stages  of  cancer  of  the  cervix. 

The  inguinal  glands  are  rarely  involved  in  the  last 
stages  of  the  disease.  Metastasis  to  remote  parts  of  the 
body  is  unusual.  Cancer  of  the  cervix  usually  remains 
localized  and  does  not  become  metastatic. 

From  this  description  it  will  be  observed  that  in  the 
early  stages  of  cancer  of  the  cervix  the  disease  presents  a 
variety  of  appearances.  As  cure  of  the  disease  depends 
upon  its  early  recognition,  it  is  of  the  utmost  importance 
that  the  physician  should  be  familiar  with  these  early 
phenomena. 

When  cancer  begins  in  an  erosion  of  a  laceration,  we 
find  that  the  eroded  surface  bleeds  more  easily  than  in  the 
non-malignant  condition,  and  is  somewhat  more  elevated 
than  the  surrounding  surface  of  the  cervix.  We  may  by 
palpation  detect  around  the  erosion  a  more  or  less  in- 
durated edge  which  is  not  felt  around  a  benign  erosion. 
The  submucous  structures  of  the  cervix  may  feel  brawny 
and  indurated.  If  the  erosion  has  become  an  ulcer,  the 
indurated  edges  and  the  involvement  of  the  deeper  struc- 
tures of  the  cervix  are  more  marked.  It  must  always  be 
remembered  that  an  ulcer  of  the  cervix  is  very  rare  as  a 
benign  condition. 

In  the  vegetating  form  of  cancer  of  the  cervix  we  may 
find  small  warty  growths,  or  large  cauliflower-like  masses, 
or  rounded  or  irregular  protuberances  growing  from  the 
surface  of  the  cervix.  There  is  here  also  felt  an  indura- 
tion around  the  base  of  the  growth  and  throughout  the 
cervix. 

A  very  striking  characteristic  of  cancerous  growths  of 
the  cervix  uteri  is  their  friability.  The  warty  growths 
or  cauliflower-like  masses  break  off  readily  upon  even 
gentle  palpation,  and  profuse  bleeding  often  results. 
There  is  no  other  disease  of  the  cervix  in  which  the 
outgrowths  are  of  such  a  friable  and  vascular  character. 
Even  in  the  ulcerated  form  of  cancer  the  edges  of  the 
nicer  are  of  this  same  friable  nature. 


CANCER  OF  THE  CERVIX  UTERI.  185 

When  the  disease  begins  immediately  within  the  ex- 
ternal OS,  this  opening  becomes  enlarged,  the  cervical 
canal  is  destroyed,  and  there  is  presented  the  appearance 
of  a  deep  conical  excavation,  with  ulcerated,  unhealthy 
edges,  in  the  center  of  the  vaginal  cervix.  When  the 
disease  begins  still  higher  up,  the  cervical  canal  may  be 
the  seat  of  extensive  destruction  of  tissue  before  any 
lesion  is  visible  below  the  external  os.  Usually,  how- 
ever, the  OS  is  sufficiently  open  to  permit  the  condition 
of  the  canal  above  to  be  seen. 

When  the  disease  begins  in  the  racemose  glands  of  the 
cervix,  the  nodules  may  be  felt  beneath  the  mucous  mem- 
brane of  the  vaginal  aspect  of  the  cervix.  The  whole 
cervix  is  usually  indurated  and  somewhat  enlarged.  The 
mucous  membrane  overlying  the  nodule  may  appear  con- 
gested, and  upon  palpation  it  is  found  that  the  overlying 
mucous  membrane  does  not  glide  readily  over  the  nodule, 
but  seems  to  be  more  than  normally  adherent  to  the 
underlying  structures. 

In  all  the  forms  of  cancer  of  the  cervix  there  is  present 
to  a  greater  or  less  extent  a  general  induration  of  the 
cervix.  The  elasticity  or  resiliency  of  the  cervix  is 
diminished  or  lost  ;  this  is  shown  not  only  by  the  sensa- 
tion upon  palpation,  but  by  the  fact  that  the  cervix  is 
not  capable  of  dilatation,  by  sponge  tent  or  otherwise,  as 
in  the  normal  condition. 

In  the  last  stages  of  the  disease  the  gross  appearance 
is  the  same  in  all  forms  of  cancer  of  the  cervix.  The 
cervix  may  fill  the  whole  vaginal  vault,  sometimes  hyper- 
trophied  to  the  size  of  the  adult  fist.  The  presenting 
-mass  is  ulcerated,  gangrenous,  and  covered  with  friable 
vegetations  bathed  in  thin  fetid  pus  and  blood.  The 
•vaginal  vault  itself  is  usually  involved  by  extension  of 
the  disease.  The  body  of  the  uterus  is  found  to  be  en- 
larged, and  the  mass  of  the  cervix  is  held  rigidly  in  the 
pelvis  by  the  thickened  cancerous  broad  ligaments. 

In  some  other  cases,  instead  of  a  protruding  mass  we 
.discover  an  immense  crater  in  the  vaginal  vault — a  era- 


1 86      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

ter  with  indurated  edges  and  sides,  surmounted  by  the 
body  of  the  uterus.  The  size  of  the  crater  shows  that 
the  destruction  of  tissue  has  extended  far  beyond  the 
normal  limits  of  the  vaginal  and  supra-vaginal  cervices. 
The  interior  of  the  crater  presents  an  ulcerated,  slough- 
ing surface. 

There  is  no  condition  which  should  be  mistaken  for 
cancer  of  the  cervix  in  the  last  stages.  A  sloughing 
uterine  polyp  presents  superficially  a  similar  appearance, 
but  the  gangrenous  mass  will  be  found  surrounded  by  a 
ring  or  collar,  often  very  attenuated,  of  healthy  cervical 
tissue,  and  the  presenting  tumor  is  usually  elastic  to  the 
touch,  not  unyielding  and  friable  like  the  cancerous  mass. 

In  the  early  stages  of  cancer  the  appearance  resembles 
closely  the  erosion  of  a  bilateral  laceration  of  the  cervix. 
In  the  simple  laceration,  however,  the  erosion  is  soft,  not 
indurated;  there  are  no  palpable  edges;  the  cervix  is  not 
brawny;  and  it  will  be  found  that  the  simple  erosion 
yields  to  local  treatment,  while  the  cancerous  erosion 
does  not. 

Syphilitic  ulceration  and  the  ulceration  of  lupus  are 
very  rare  upon  the  cervix.  Syphilitic  ulceration  some- 
times presents  all  the  gross  appearances  of  cancer.  The 
history,  the  microscopical  examination,  and  the  thera- 
peutic test  will  enable  one  to  make  a  differential  diag- 
nosis. 

Cystic  degeneration  of  the  cervix  should  not  be  mis- 
taken for  the  nodular  form  of  cancer,  for  the  cysts  may 
be  seen  and  punctured  and  their  character  determined. 

Benign  fibroid  tumors  of  the  cervix  are  very  rare, 
are  usually  single,  and  are  larger  than  the  nodules  of 
cancer. 

In  every  case  of  doubt,  in  every  case  in  which  the 
physician  has  the  least  cause  to  suspect  malignancy, 
microscopic  examination  of  an  excised  portion  of  tissue 
should  be  made.  Examination  of  tissue  scraped  off 
should  not  be  relied  upon.  The  most  suspicious  portion 
of  tissue  should  be  seized  with  a  tenaculum  and  freely 


CANCER  OF  THE  CERVIX  UTERI.  1 87 

cut  out.  Pieces  of  tissue  may  be  thus  excised  from  two 
or  more  situations.  In  the  nodular  form  of  cancer  a 
nodule  should  be  seized  and  excised.  It  is  perfectly 
justifiable,  in  cases  which  cannot  thus  be  elucidated,  to 
amputate  the  cervix  and  examine  the  whole  structure. 

The  excision  of  small  pieces  of  tissue  may  be  done 
without  an  anesthetic,  as  little  or  no  pain  is  caused  by 
the  operation.  Bleeding  is  very  slight,  and  may  always 
be  controlled  by  a  light  vaginal  compress  of  gauze  or 
cotton.  If  the  case  is  not  malignant,  healing  is  rapid. 
The  specimen  removed  should  be  placed  in  absolute 
alcohol  and  submitted  to  microscopical  examination  by  an 
experienced  pathologist. 

Symptoms  of  Cancer  of  the  Cervix. — A  study  of 
the  early  symptoms  of  cancer  of  the  cervix  is  of  the 
greatest  importance.  In  the  early  stages  the  disease  may 
be  eradicated  with  every  probability  of  permanent  cure. 
Cancer  of  the  uterus  is  more  favorable  for  surgical  attack 
than  cancer  in  most  other  parts  of  the  body.  Excision 
of  the  disease  is  not  done  in  the  continuity  of  an  organ 
or  a  structure,  but  the  whole  organ  attached  by  distinct 
structures  may  be  removed. 

The  great  majority  of  women  with  cancer  of  the  cer- 
vix come  to  the  operator  when  the  disease  has  extended 
too  far  to  permit  any  radical  treatment.  Hopeless  pal- 
liation is  the  only  course  to  be  followed.  This  unfortu- 
nate condition  of  things  is  due  to  the  ignorance  of  the 
woman  in  regard  to  the  significance  of  the  early  symp- 
toms of  the  disease,  and  to  the  failure  of  the  physician 
first  consulted  to  insist  upon  a  thorough  examination  as 
soon  as  any  suspicious  symptoms  appear. 

There  is  no  one  symptom  of  cancer  of  the  cervix 
present  in  all  cases,  and  all  the  common  symptoms  may 
be  absent  in  exceptional  cases  until  the  last  stages  of  the 
disease — until  the  disease  has  extended  so  far  that  cure 
is  impossible.  It  is  of  great  importance  to  remember  this 
fact,  so  that  the  absence  of  one  or  more  of  the  classical 
symptoms  of  cancer  shall  not  engender  a  feeling  of  secur- 


loo      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

ity  that  may  cause  the  postponement  of  a  thorough 
physical  examination. 

The  usual  symptoms  of  cancer  of  the  cervix  are  hem- 
orrhage, pain,  and  discharge. 

Hemorrhage. — The  first  symptom  that  should  direct 
our  attention  to  this  disease  is  bleeding  from  the  vagina. 
Such  hemorrhage  often  first  appears  as  a  menorrhagia — 
as  an  increase  in  the  amount  of  blood  lost  at  the  normal 
menstrual  periods.  The  loss  of  blood  may  be  greater, 
and  the  duration  of  the  period  longer.  Sometimes,  if 
the  woman  keeps  quiet  during  the  period,  the  loss  of 
blood  and  the  duration  are  about  as  usual;  but  if  she  is 
upon  her  feet  the  loss  is  increased,  and  if  she  begins  an 
active  life  immediately  after  the  usual  duration  of  the 
menstrual  period  has  elapsed,  bleeding  may  reappear  for 
one  or  more  days. 

In  other  cases  slight  bleeding  appears  in  the  menstrual 
interval.  A  spot  of  blood  may  be  discovered  upon  the 
clothing.  The  accustomed  leucorrheal  discharge  may 
occasionally  be  streaked  with  blood.  Such  appearances 
are  most  frequent  after  long  walking  or  standing  or  phys- 
ical work,  or  after  straining  at  stool,  or  very  often  after 
coitus. 

If  the  woman  has  passed  the  menopause,  the  hemor- 
rhage of  cancer  may  appear  as  a  re-establishment  of  men- 
struation— often  to  the  satisfaction  of  the  woman.  This 
post-climacteric  bleeding  may  occur  with  more  or  less 
regularity — every  month  or  every  three  or  four  months — 
or  it  may  appear  as  an  occasional  loss  of  blood  after  un- 
wonted effort. 

All  hemorrhage  of  this  kind,  in  women  over  thirty 
years  of  age,  demands  immediate  and  careful  physical 
examination.  Any  bleeding  from  the  vagina  in  a  woman 
who  has  passed  the  menopause  should  arouse  the  gravest 
suspicion.  From  the  slight  hemorrhages  just  described 
the  bleeding  increases  in  intensity  and  duration,  until 
there  is  a  continuous  loss  of  blood  that  saps  the  strength 
of  the  woman  and  produces  the  profound  anemia  cha- 


CANCER  OF  THE  CERVIX  UTERI.  189 

racteristic  of   the  last  stages   of   cancer  of   the  cervix, 
Sudden  fatal  hemorrhage  in  this  disease  is  rare. 

Pain  is  not  a  constant  accompaniment  of  cancer  of 
the  cervix  in  the  early  stages,  nor  is  it  in  any  way  cha- 
racteristic. The  intensity  and  character  of  the  pain  may 
depend  upon  the  direction  of  the  growth  of  the  disease. 
In  some  cases  pain  is  absent  throughout.  The  pain  may 
be  dull  and  gnawing  in  character,  or  it  may  be  sharp  and 
lancinating.  The  pain  may  resemble  that  of  uterine 
colic.  It  may  be  referred  to  the  back  in  the  region  of 
the  sacrum,  or  to  one  or  both  ovarian  regions,  or  to  some 
part  of  the  pelvis  remote  from  the  uterus,  as  the  crest  or 
the  anterior  superior  spine  of  the  ilium.  It  may  extend 
down  the  posterior  or  anterior  aspects  of  the  thighs  or 
into  the  rectum.  In  most  cases  of  cancer  of  the  cervix 
pain  is  not  a  prominent  symptom  until  the  later  stages. 

Discharge  from  the  vagina  may  be  present  in  cancer  of 
the  cervix  before  there  are  any  symptoms  of  hemorrhage 
or  pain.  The  discharge  depends  upon  the  position  and 
character  of  the  growth  and  the  stage  of  the  disease.  It 
may  first  appear  as  an  ordinary  cervical  leucorrhea  in  a 
woman  previously  free  from  such  discharge;  or  the  dis- 
charge of  cancer  may  first  appear  as  an  increase  of  an 
accustomed  leucorrhea.  In  such  cases  it  is  due  to  hyper- 
secretion from  the  irritated  cervical  glands. 

lyater  in  the  disease,  when  ulceration  takes  place  or 
when  the  friable  vascular  vegetations  appear,  the  leucor- 
rhea becomes  puriform  in  character  and  streaked  with 
blood.  It  then  becomes  thinner,  less  mucous  in  consist- 
ency, and  of  a  constant  brownish  color  from  the  admix- 
ture of  blood.  The  pus  and  debris  from  the  breaking- 
down  cancerous  mass  increase,  and  a  horrible  odor 
characteristic  of  the  later  stages  of  cancer  of  the  cervix 
appears.  This  odor  is  not  peculiar  to  cancer.  It  is 
caused  by  the  sloughing  tissue,  and  is  observed  when 
such  a  process  occurs  in  other  conditions,  as  in  sloughing 
fibroid  polyp.  The  discharge  is  irritating  in  character, 
and  the  ostium  vaginae,  the  vulva,  and  the  inner  aspects 


190       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

of  the  thighs  become  excoriated  in  those  who  do  not  ob- 
serve strict  cleanliness. 

Systemic  absorption  of  the  cancerous  discharges  pro- 
duces a  general  septic  condition,  which,  with  the  anemia 
from  hemorrhage  and  the  uremia  from  obstruction  of  the 
ureters,  results  in  the  so-called  cancerous  cachexia. 

The  symptoms  that  have  just  been  described  are  those 
most  usual  in  cases  of  cancer.  It  must  always  be  re- 
membered, however,  that  these  symptoms  vary  very  much 
in  intensity  or  prominence  and  in  the  stage  of  the  disease 
at  which  they  appear.  Sometimes  acute  pain,  hemor- 
rhage, and  excessive  discharge  are  present  from  the  very 
beginning — even  before  the  presence  of  cancer  can  be 
demonstrated  without  the  aid  of  the  microscope.  In 
other  cases  all  these  symptoms  may  be  absent  until  the 
disease  is  very  far  advanced.  None  of  the  symptoms  are 
absolutely  pathognomonic  of  cancer.  During  the  men- 
strual life  of  the  woman  hemorrhage  from  the  womb 
occurs  as  a  symptom  of  a  great  variety  of  diseases;  and 
even  in  the  post-climacteric  period,  though  hemorrhage 
should  always  excite  alarm,  yet  it  may  be  caused  by  a  be- 
nign form  of  endometritis  or  intra-uterine  growth.  The 
pain  of  cancer  may  also  characterize  a  variety  of  benign 
conditions;  and  the  vaginal  discharge,  even  when  most 
offensive,  may  be  simulated  by  that  from  a  sloughing 
intra-uterine  fibroid. 

The  symptoms,  however  slight,  which  we  know  may 
occur  with  cancer  of  the  cervix  should  never  be  dis- 
regarded. Examination  should  be  made  immediately. 
There  should  be  no  postponement  or  expectant  plan  of 
treatment.  If  physical  examination  is  not  satisfactory  in 
elucidating  the  condition,  resort  should  be  had  to  the 
microscope.  If  this  is  not  conclusive,  the  case  should  be 
watched  as  long  as  the  suspicious  symptoms  continue,  and 
further  frequent  examinations  should  be  made. 

If  this  plan  of  treatment  is  followed,  and  if  women  are 
taught  to  view  with  distrust,  and  not  with  complacency, 
any  irregularities  of  menstruation  occurring  near  the  time 


CANCER  OF  THE  CERVIX  UTERI.  iqi 

of  the  menopause,  or  any  post-climacteric  return  of  men- 
struation or  of  irregular  bleeding,  the  surgeon  will  be 
able  to  save  many  women  with  cancer  of  the  womb  who 
are  now  doomed  to  horrible  deaths. 

Cancer  of  the  cervix,  like  cancer  in  other  parts  of  the 
body,  is  of  variable  duration.  Usually  from  one  to  three 
years  elapse  between  the  time  when  the  first  symptoms 
of  the  disease  appear  and  the  time  of  death.  The  dis- 
ease may  run  its  course,  in  exceptional  cases,  in  a  few 
weeks;  in  other  cases  it  may  last  as  long  as  five  years, 
especially  if  the  progress  is  delayed  by  palliative  treat- 
ment. 

Treatment.— Complete  removal  of  the  uterus  is  the 
only  curative  treatment  for  cancer  of  the  cervix.  If  the 
disease  is  seen  in  the  earliest  stages,  amputation  of  the 
cervix  beyond  the  limits  of  the  growth  seems,  theoreti- 
cally at  least,  to  be  a  proper  plan  of  treatment.  Prac- 
tically, however,  the  operator  can  never  be  certain  that 
the  excision  is  made  in  healthy  tissue.  The  senses  of 
touch  and  unaided  sight  are  not  capable  of  defining  the 
limits  of  malignant  infiltration.  Moreover,  it  must  be 
remembered  that  the  endometrium  is  very  often  involved 
secondarily  from  a  cancerous  focus  in  the  cervix.  Com- 
plete removal  of  the  uterus  should  therefore  always  be 
practised  in  all  cases  in  which  there  is  a  possibility  of 
removing  all  of  the  disease. 

The  manner  of  performing  this  operation  will  be 
described  subsequently. 

The  cases  that  are  not  suitable  for  the  operation  of 
hysterectomy  are  those  in  which  the  disease  has  extended 
to  structures  that  are  surgically  inaccessible.  Such  cases 
include  those  in  which  the  bladder  or  the  rectum  are  in- 
volved, those  in  which  the  vagina  is  extensively  impli- 
cated, and  those  in  which  the  disease  has  extended  into 
the  broad  ligaments  or  the  cellular  tissue  of  the  pelvis. 

When  the  bladder  is  involved,  there  are  dysuria,  vesical 
pain,  and  tenderness  on  vaginal  pressure  upon  the  base 
of  the  bladder,  while  the  urine  is  altered  in  character, 


192       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

containing  blood,  pus,  and,  in  the  later  stages,  broken- 
down  necrotic  tissue.  Involvement  of  the  rectum  is 
manifest  by  digital  examination. 

When  the  broad  ligaments  are  involved  the  uterus  is 
held  rigidly  in  the  pelvis  or  is  drawn  to  one  side,  and  the 
bases  of  the  broad  ligaments,  palpated  through  the  lateral 
vaginal  fornices,  are  thick  and  hard.  When  the  cellular 
tissue  of  the  pelvis  is  generally  involved  the  whole  vag- 
inal vault  feels  indurated  and  the  uterus  seems  fixed  in 
the  unyielding  matrix. 

In  examining  with  the  view  of  determining  the  prac- 
ticability of  hysterectomy,  it  is  important  to  distinguish 
between  cancerous  and  simple  inflammatory  involvement 
of  the  broad  ligaments.  The  uterus  may  be  fixed  in  the 
pelvis  by  inflammatory  adhesions  resulting  from  old  tubal 
disease,  and  yet  the  cancer  of  the  cervix  may  be  strictly 
local  and  in  a  stage  suitable  for  hysterectomy.  In  the 
simple  inflammatory  cases  the  adhesions  are  more  atten- 
uated, are  higher  in  the  pelvis,  and  lie  chiefly  posterior  to 
the  uterus.  They  are  not  directly  continuous  with  the 
cervix.  Frequently  the  enlarged  tube  and  the  adherent 
ovary  may  be  felt.  When  the  uterus  is  fixed  by  cancer- 
ous involvement  of  the  broad  ligament,  we  readily  feel 
that  it  is  the  base  of  the  broad  ligament  that  is  involved. 
The  induration  is  broad,  it  is  directly  continuous  with 
the  induration  of  the  cervix,  and  it  lies  to  the  side  of  the 
uterus. 

Involvement  of  the  pelvic  lymphatic  glands  may  some- 
times be  determined  by  vaginal  palpation,  one  or  more 
such  enlarged  indurated  glands  being  felt  lying  posterior 
to  the  uterus.  In  most  cases,  however,  glandular  in- 
volvement can  be  determined  only  after  the  abdomen  has 
been  opened. 

In  general,  it  may  be  said  that  the  operation  of  hyster- 
ectomy should  be  performed  in  all  cases  in  which  there 
is  no  cancerous  involvement  of  the  bladder  and  rectum, 
in  which  the  vaginal  disease  may  all  be  removed,  and  in 
which  the  uterus  is  freelv  movable. 


CANCER  OF  THE  CERVIX  UTERI.  1 93 

In  those  cases  in  which  complete  removal  of  the  dis- 
ease is  impossible  the  operation  of  hysterectomy  should 
not  be  performed,  because,  cure  being  out  of  the  ques- 
tion, the  symptoms  of  hemorrhage,  pain,  and  discharge 
may  be  as  well  relieved  by  less  dangerous  forms  of  pallia- 
tive treatment.  When  the  disease  extends  beyond  the 
limits  of  the  uterus,  hysterectomy  is  much  more  difficult 
and  dangerous  than  when  the  uterus  is  freely  movable. 

The  remote  results  of  hysterectomy  for  cancer  of  the 
cervix  are  poor.  In  the  very  great  majority  of  all  cases 
submitted  to  operation  recurrence  has  taken  place.  It 
seems  very  probable  that  a  few  of  the  cases  of  recurrence 
are  due  to  transplantation  of  cancer-cells  into  healthy 
tissue  during  the  operation;  but  the  vast  majority  die 
because  all  of  the  diseased  tissues  have  not  been  or  can 
not  be  removed.  The  hope  for  better  results  from  the 
surgical  treatment  of  cancer  of  the  cervix  depends,  not 
upon  improvement  in  the  surgical  technique,  but  upon 
the  ability  of  the  general  practitioner  to  recognize  the 
disease  in  its  earliest  stages,  before  inaccessible  structures 
have  been  involved. 

Palliative  Treattnent  of  Cancer  of  the  Cervix. — The 
palliative  treatment  consists  in  removing  as  thoroughly 
as  possible,  with  the  sharp  spoon-curette,  scissors,  or 
knife,  all  the  cancerous  cervix,  and  the  maintenance  of 
the  surfaces  thus  exposed,  as  far  as  possible,  free  from 
septic  infection. 

The  woman  should  be  placed  in  the  lithotomy  position; 
the  cervix  should  be  exposed  with  the  Sims  speculum 
and,  if  necessary,  with  the  lateral  vaginal  retractors. 
All  vegetations  and  all  of  the  degenerated  cervix  should 
then  be  cut  away.  It  is  usually  necessary  to  carry  "the 
excision  of  tissue  as  high  as  the  internal  os.  Bleeding 
during  this  procedure  is  sometimes  very  profuse.  It 
diminishes,  however,  as  the  more  degenerated  portions  of 
the  cervix  are  cut  away  and  the  healthier  uterine  tissue 
is  reached,  and  therefore  it  is  always  best  to  complete  the 
operation,  notwithstanding  hemorrhage. 

13 


194     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  bleeding  may  be  controlled  by  packing  the  cavity 
with  gauze  or  cotton,  plain  or  saturated  with  Monsel's 
solution.  Moderate  bleeding  may  be  checked  by  packing 
with  cotton  saturated  with  a  5  per  cent,  solution  of  anti- 
pyrine. 

In  rare  cases,  in  which  the  excision  of  tissue  has  been 
carried  high  up  in  the  lateral  vaginal  fornices,  it  may  be 
necessary  to  ligate  the  uterine  arteries  in  order  to  control 
the  hemorrhage.  This  may  be  done  by  passing  around 
the  vessel,  close  to  the  cervix,  a  curved  needle  carrying 
a  heavy  ligature.  Bleeding  from  the  circular  artery  may 
readily  be  controlled  in  a  similar  way,  the  ligature  being 
passed  like  the  first  suture  in  trachelorrhaphy. 

If  the  operation  has  been  thoroughly  performed,  there 
will  be  left  a  large  crater  or  conical  cavity  in  the  vaginal 
vault.  This  cavity  may  then  be  packed  with  sterile 
gauze,  or,  if  there  is  much  bleeding,  with  gauze  saturated 
with  Monsel's  solution.  Martin  sews  together  the  walls 
of  the  cavity  to  diminish  as  much  as  possible  the  raw 
surface.  Other  operators  char  the  walls  with  the  actual 
cautery,  in  order  to  carry  the  destruction  of  tissue  still 
farther  than  has  been  done  with  the  knife.  If  the  re- 
moval with  the  curette  and  knife  has  been  thorough,  it  is 
not  necessary  to  make  a  caustic  application.  If,  how- 
ever, the  cavity  is  walled  by  obviously  cancerous  tissue, 
the  use  of  the  caustic  is  advisable.  This  is  usually  the 
case. 

Chloride  of  zinc  is  a  valuable  caustic  in  cancer  of  the 
cervix.  It  should  be  applied  as  follows:  After  the  can- 
cerous tissue  has  been  removed  as  thoroughly  as  possible 
with  the  knife,  the  scissors,  and  the  curette,  bleeding 
from  the  walls  of  the  cavity  should  be  checked  by  pack- 
ing with  gauze,  dry  or  saturated  with  a  5  per  cent,  solu- 
tion of  antipyrine.  The  bleeding  may  very  often  be 
checked  in  this  way  in  a  few  minutes,  and  in  this  case 
the  caustic  may  be  immediately'  applied.  In  case,  how- 
ever, the  bleeding  is  not  so  quickly  controlled,  the  pack- 
ing must  be  left  in  the  cavity  for  twenty-four  hours,  at 


CANCER  OF  THE  CERVIX  UTERI.  195 

the  end  of  which  time  it  may  be  removed,  without  anes- 
thesia, and  the  caustic  application  may  be  made. 

Before  introducing  the  caustic  the  vagina  and  the  vulva 
should  be  protected  by  thorough  greasing  with  an  oint- 
ment composed  of  i  part  of  bicarbonate  of  soda  to  3 
parts  of  vaseline. 

The  strength  of  the  caustic  should  depend  somewhat 
upon  the  thickness  of  the  tissue  that  separates  the  cavity 
from  the  peritoneum  or  other  important  structures.  The 
thickness  may  be  approximately  determined  by  palpation. 
Usually  a  100  per  cent,  solution  of  chloride  of  zinc  may 
be  safely  employed.  If  the  walls  of  the  cavity  appear 
very  thin — less  than  a  quarter  of  an  inch — the  caustic 
may  be  reduced  to  a  50  per  cent,  solution.  Small  balls 
of  cotton,  about  half  an  inch  in  diameter,  should  be 
saturated  with  the  caustic  and  carefully  packed  in  the 
cavity.  The  operator  should  be  careful  to  remove  quickly 
with  the  sponge  any  excess  of  caustic  that  may  be  ex- 
pressed from  the  cotton.  Much  unnecessary  pain  may  be 
experienced  if  the  caustic  comes  in  contact  with  the  va- 
gina or  the  vulva. 

When  the  cavity  has  been  filled  with  the  cotton  balls 
carrying  the  chloride  of  zinc,  a  large  vaginal  tampon  of 
cotton  well  greased  with  the  alkaline  ointment  should  be 
placed  in  the  vaginal  vault.  The  packing  should  be  re- 
moved from  the  vagina  in  forty-eight  hours,  and  vaginal 
douches  of  bichloride  of  mercury,  i  :  4000,  should  be  ad- 
ministered. 

If  this  operation  is  carefully  performed,  the  subsequent 
pain  is  usually  slight.  In  some  cases,  however,  the 
action  of  the  ca,ustic  may  be  so  painful  that  morphine  is 
required. 

The  slough  from  the  caustic  may  be  discharged  in  one 
piece  or  in  shreds.  It  is  usually  separated  in  from  five 
to  ten  days. 

The  subsequent  treatment  of  the  woman  consists  in  the 
frequent  use  of  cleansing  vaginal  douches,  such  as  a  solu- 
tion of  bichloride  of  mercury  (i  :  4000),  carbolic  acid  (3 


196      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

per  cent,  solution),  permanganate  of  potash  (10  grains  to 
the  ounce  of  water),  and  peroxide  of  hydrogen  (i  part  of 
the  commercial  peroxide  to  3  or  4  parts  of  water). 

The  palliative  treatment  of  cancer  relieves  the  pain, 
the  hemorrhage,  and  the  discharge.  The  relief  is  usually- 
immediate,  and  may  continue  throughout  the  disease. 
The  hemorrhage  is  usually  arrested  for  several  weeks,  or 
even  for  months,  and  the  discharge  is  much  diminished 
with  the  destruction  of  the  necrotic  cancerous  mass. 
The  progress  of  the  disease  is  delayed,  and  life  is  some- 
what prolonged. 


CHAPTER   XVII. 
DISEASES  OF  THE  BODY  OF  THE  UTERUS. 

ACUTE  CORPOREAL  ENDOMETRITIS. 

Acute  inflammation  of  the  mucous  membrane  of  the 
body  of  the  uterus  is  called  acute  corporeal  endometritis. 
The  disease  is  usually  the  result  of  septic  infection  occur- 
ring at  a  labor  or  a  miscarriage.  Occasionally  acute 
gonorrheal  endometritis  is  seen,  but  this  disease  usually 
produces  an  inflammation  of  the  mucous  membrane  of  the 
cervix  and  the  body  of  the  uterus  that  is  chronic  or  sub- 
acute from  the  beginning.  Septic  infection  through 
operative  traumatism,  through  the  use  of  the  uterine 
sound,  or  through  other  gynecological  methods  of  exam- 
ination may,  of  course,  result  in  acute  endometritis. 

The  pathological  changes  that  take  place  in  an  endo- 
metrium that  is  the  seat  of  acute  inflammation  resemble 
those  seen  in  acute  inflammation  of  mucous  membranes 
of  other  parts  of  the  body.  The  secretion  of  the  utricular 
glands  becomes  much  increased  in  quantity  and  altered 
in  character,  becoming  purulent  and  sometimes  contain- 
ing blood. 

As  would  be  expected,  whenever  the  inflammation  is  at 
all  severe  the  middle  or  muscular  coat  of  the  uterus 
is  involved  by  the  process;  in  other  words,  a  metritis 
follows  and  accompanies  the  endometritis.  In  puerperal 
metritis  abscesses  varying  in  size  from  a  pin-head  to  that 
of  a  hen's  ^^<g  are  sometimes  found  in  the  uterine  wall. 

The  septic  infection  may  extend  through  the  muscular 
wall  of  the  uterus  and  involve  the  peritoneal  covering, 
producing  in  this  way  a  perimetritis. 

Acute  inflammation  of  the  endometrium  sometimes 
occurs   during   the   course   of    the    exanthemata.       The 

197 


198     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

changes  that  take  place  in  the  mucous  membrane  of  the 
uterus  are  similar  to  those  seen  in  other  mucous  membranes 
during  the  course  of  these  diseases.  The  local  condition 
is  usually  limited  by  the  duration  of  the  general  disease. 

It  is  probable  that  some  of  the  cases  of  arrested  de- 
velopment of  the  internal  organs  of  generation,  and  cases 
of  chronic  tubal  and  ovarian  disease  seen  in  later  life, 
may  be  traced  to  this  exanthematous  form  of  endometritis 
occurring  during  girlhood. 

The  symptoms  of  acute  endometritis  vary  very  much 
in  severity.  Dull  pain  in  the  region  of  the  uterus, 
referred  to  the  supra-pubic  region  and  the  sacrum,  is 
usually  present.  Reflex  disturbance  of  the  bladder,  cha- 
racterized by  frequent  and  often  painful  urination,  may 
be  present;  and  it  is  very  probable  that  mild  cases  of 
endometritis  have  been  diagnosed  and  treated  as  light 
attacks  of  cystitis.  The  temperature  in  the  puerperal 
cases  may  be  very  high.  The  discharge  from  the  cervix 
is  very  much  increased,  is  puriform  in  character,  and  is 
occasionally  streaked  with  blood. 

Digital  examination  shows  that  the  external  os  is  patu- 
lous, the  cervix  enlarged  and  soft,  and  the  body  of  the 
uterus  somewhat  enlarged  and  tender  upon  pressure. 
This  tenderness  may  be  elicited  by  pressing  the  fundus 
between  the  vaginal  finger  in  the  anterior  vaginal  fornix 
and  the  abdominal  hand.  Examination  through  the 
speculum  shows  the  discharge  escaping  from  the  exter- 
nal OS.  In  case  the  cervical  mucous  membrane  is  also 
involved,  a  red  area  of  erosion  will  be  seen  surrounding 
the  OS. 

Acute  endometritis  of  non-puerperal  origin  is  best 
treated  by  rest  in  bed,  vaginal  douches  of  hot  boric- 
acid  solution  (.^j  to  a  pint  of  water)  or  of  bichloride  of 
mercury  (i  14000)  at  a  temperature  of  100°  to  110°,  and 
the  continuous  use  of  saline  purgatives.  Active  intra- 
uterine treatment  in  these  cases  is  not  necessary. 
When,  however,  the  disease  occurs,  as  it  usually  does, 
from  septic  infection  at  a  miscarriage  or  a  labor,   more 


DISEASES  OF  THE  BODY  OF  THE  UTERUS.    199 

radical  treatment  must  be  used.  This  treatment  com- 
prises frequently-repeated  intra-uterine  douches,  thorough 
curetting  of  the  uterus,  and,  finally,  hysterectomy  in 
extreme  cases. 

Every  case  of  acute  endometritis  should  be  carefully 
watched  and  treated  until  the  disease  is  cured,  x^cute 
endometritis,  especially  if  gonorrhea  is  the  cause,  is  very 
prone  to  become  chronic  and  to  extend  to  the  mucous 
membrane  of  the  Fallopian  tubes  and  the  ovaries. 

CHRONIC    CORPOREAL    ENDOMETRITIS. 

Chronic  inflammation  of  the  endometrium,  or  chronic 
endometritis,  is  much  more  frequently  seen  in  practice 
than  the  acute  form.  It  may  occur  as  a  primary  dis- 
ease, but  it  very  often  occurs  as  the  result  of  some  other 
pathological  condition  of  the  uterus,  as,  for  instance,  sub- 
involution or  uterine  fibroid. 

A  variety  of  confusing  terms  have  been  used  to  desig- 
nate the  different  forms  of  endometritis.  There  seem  to 
be  two  chief  forms  of  the  disease:  I.  Chronic  interstitial 
endometritis;  II.   Chronic  glandular  endometritis. 

In  the  first  form  of  the  disease  the  interglandular  tissue 
is  chiefly  involved.  The  spaces  between  the  glands  are 
infiltrated  with  connective-tissue  cells. 

In  the  second  or  glandular  form  of  endometritis  the 
disease  aflects  the  glandular  apparatus.  The  utricular 
glands  become  much  elongated,  branched,  and  increased 
in  number.  The  accompanying  illustrations  (Figs.  117, 
118)  show  the  microscopic  appearance  of  interstitial  en- 
dometritis and  glandular  endometritis. 

These  two  forms  of  endometritis  are  often  mixed,  and 
the  same  uterus  may  present  the  glandular  form  of  in- 
flammation upon  part  of  the  endometrium,  the  intersti- 
tial form  upon  another  part,  and  the  mixed  form  upon 
still  another  part. 

The  gross  appearance  of  the  endometrium  varies  with 
the  form  of  the  disease  and  its  duration.  It  will  be  re- 
membered that  in  the  mature  uterus,  in  the  menstrual 


<-.-' 


^^ 


Pig.    117. — Interstitial    endometritis:    microscopic    section   of   endometriur 
removed  by  the  curette  (Beyea). 

^..^"•"^*^r'""' — -"•""- " ■ • ., 


11'^. — i-jlaiuluiar    L'i!iluinftnti>  :    niicru.^C' ipic    :-cuti(jn    of   endometriur 
reini.j\Lii   by  the  curette   (Beyea). 


~  >■    '•:-  \t^ 


yi 


i^'".. 


i 

,.'-J 


/:5 


^?^ 
''>. 


.^^1. 


-«  "•  ,;   /  >v,i  ;? 

iiy. — lulypuid  (.  nduiiietritis  (Beyea). 


/  .5    ,. 


// 


DISEASES  OF  THE  BODY  OF  THE  UTERUS.    20i 

interval,  the  mucous  membrane  is  a  thin  reddish-gray 
structure  about  i  millimeter  (2V  inch)  in  thickness.  In 
the  different  forms  of  endometritis  the  mucous  membrane 
may  become  hypertrophied  to  three  or  four  times  this 
thickness.  In  some  unusual  cases  the  mucous  membrane 
may  become  even  still  further  hypertrophied,  attaining 
a  thickness  of  half  an  inch.  A  special  name,  fungozis 
endometritis^  has  been  given  to  the  disease  when  it  as- 
sumes this  form.  Microscopic  examination  shows  that 
fungous  endometritis  is  merely  a  mixed  form  of  the 
glandular  and  the  interstitial  varieties,  with  a  great  in- 
crease of  all  the  elements  of  the  mucous  membrane.  In 
fungous  endometritis  the  hypertrophy  of  the  mucous 
membrane  may  be  uniform  throughout  the  body  of  the 
uterus  or  it  may  occur  only  in  localized  areas. 

In  some  cases  the  glandular  hypertrophy  of  the  mucous 
membrane  assumes  the  form  of  polypoid  growths  project- 
ing into  the  uterine  cavity  (Fig.  119). 

In  the  advanced  stages  of  all  the  forms  of  endometritis 
cicatricial  formation  takes  place.  The  normal  ciliated 
.epithelium  of  the  endometrium  is  cast  off,  and  is  replaced 
by  flat  squamous  cells.  The  glands  atrophy;  the  glandu- 
lar openings  become  dilated,  and  ultimately  appear  as 
:simple  depressions  on  the  surface.  In  time  secretion 
from  the  glands  ceases,  and  the  cavity  of  the  uterus  be- 
.comes  lined  with  simple  connective  tissue. 

Chronic  endometritis  is  always  accompanied  to  a  greater 
.or  less  extent  by  inflammation  of  the  muscular  coat  of 
-the  uterus.  The  pathological  changes  that  take  place  re- 
-semble  those  occurring  in  chronic  inflammation  in  similar 
musculo-fibrous  structures  in  other  parts  of  the  body. 
A  section  of  the  uterine  wall  is  much  lighter  in  appear- 
ance than  normal,  and  the  whitish  bundles  of  connective 
■tissue  are  seen  interlacing  with  the  more  vascular  muscu- 
lar fibers. 

At  first  there  is  an  hypertrophy  of  the  uterine  wall 
from  infiltration  of  inflammatory  material.  In  the  latest 
;Stages  organized  connective  tissue  is  formed,  and  there  is 


202      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

produced  a  sclerotic  condition  of  the  uterus,  with  atrophy 
of  its  normal  muscular  elements. 

The  hypertrophy  of  the  uterus,  however,  that  accom- 
panies most  of  the  forms  of  endometritis  is  not  due  alto- 
gether to  the  presence  of  inflammatory  deposits.  The 
uterus  possesses  the  peculiar  property  of  enlarging,  by 
a  general  hypertrophy  of  its  elements,  whenever  there  is 
present  in  its  cavity  any  gross  pathological  condition. 
We  see  this  in  fibroid  tumor.  And,  as  a  oreneral  rule, 
the  enlargement  is  proportional  to  the  mensurable  size 
of  the  disease. 

The  metritis  may  involve  the  whole  of  the  uterine 
body,  or  it  may  occur  in  localized  areas.  It  may  affect 
only  the  body  of  the  uterus,  or  the  body  and  the  cervix, 
or,  as  we  have  already  seen,  the  cervix  alone.  When  the 
disease  is  localized  to  part  of  the  uterine  wall,  the  indu- 
ration of  the  affected  area  may  sometimes  be  determined 
by  palpation. 

Sjrmptoms. — The  symptoms  of  chronic  endometritis 
are  often  obscured  by  symptoms  that  are  to  be  referred 
to  other  accompanying  conditions.  For  instance,  the 
endometritis  very  often  accompanies  subinvolution  of 
the  uterus,  laceration  of  the  cervix,  uterine  displace- 
ment, or  ovarian  and  tubal  disease.  Cases  of  simple 
uncomplicated  endometritis  are  the  exception. 

The  menstrual  function  is  usually  affected.  The  period 
is  of  longer  duration,  the  loss  of  blood  is  greater,  and 
the  periods  may  occur  more  frequently  than  normal;  in 
other  words,  there  is  present  menorrhagia.  In  this  dis- 
ease bleeding  also  occasionally  occurs  between  the  men- 
strual periods.  Hemorrhage  is  a  symptom  that  is  most 
prominent  in  cases  of  interstitial  and  fungoid  endo- 
metritis. 

The  secretion  of  the  utricular  glands  is  also  increased 
in  amount.  This  symptom  is  most  pronounced  in  cases 
of  glandular  endometritis.  The  secretion  is  thin  and 
purulent  in  character,  and  is  often  streaked  with  blood. 
It  decomposes  very  readily,   and  consequently   is  often 


DISEASES  OF  THE  BODY  OF  THE  UTERUS.    203 

offensive   and   excites   the   suspicion    of  malignant   dis- 
ease. 

The  character  of  the  typical  discharge  from  the  body 
of  the  uterus  is  usually  obscured  by  admixture  with  dis- 
charge from  the  cervical  mucous  membrane.  Cervical 
catarrh,  or  inflammation  of  the  cervical  mucous  mem- 
brane, may,  and  usually  does,  occur  alone,  without  in- 
volvement of  the  upper  endometrium,  but  chronic  cor- 
poreal endometritis  is  usually  associated  with  inflamma- 
tion of  the  cervix.  If  the  discharge  is  observed  at  the 
vulva,  it  will  be  still  further  altered  by  admixture  with 
the  vaginal  secretion.  The  discharge  from  the  corporeal 
endometrium  is  thinner  and  more  serous  than  the  mucus 
of  the  cervical  canal,  and  is  more  usually  purulent  and 
streaked  with  blood. 

The  discharge  from  the  endometrium  is  very  often  in- 
creased very  decidedly  immediately  before  and  after  the 
menstrual  period. 

Pain  is  a  general  symptom  of  chronic  endometritis. 
The  pain  is  uterine  in  character,  and  is  referred  to  the 
lower  abdomen  and  the  back:  There  is  also  very  con- 
stantly present  reflex  headache  localized  on  the  top  of 
the  head  or  in  the  occiput. 

The  pain  may  be  present  at  all  times,  but  it  is  usually 
most  marked  when  the  woman  is  upon  her  feet  and  the 
pelvic  congestion  is  increased.  The  pain  is  always  great- 
est immediately  before  and  during  the  menstrual  period. 
General  physical  weakness  and  debility  are  often  very 
pronounced,  and  seem  to  be  out  of  proportion  to  the 
extent  of  the  local  disease.  This  same  phenomenon  has 
been  spoken  of  in  the  consideration  of  uterine  displace- 
ments. The  weak  and  aching  back,  the  dragging  sensa- 
tions in  the  pelvis,  the  tired  legs,  may  all  appear  after 
the  woman  has  been  upon  her  feet  but  a  short  time,  and 
utterly  incapacitate  her  for  any  kind  of  labor. 

Nervousness,  neurasthenia,  hysteria,  and  mental  de- 
pression and  melancholia  are  apt  to  occur  in  this  disease. 
Such  nervous  phenomena  are  common  to  all  diseases  of 


204     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

the  uterus.  The  mental  depression  is  often  very  marked, 
and  is  exaggerated  before  and  during  each  menstrual 
period. 

The  woman  with  chronic  endometritis  is  usually 
sterile;  or  if  she  becomes  pregnant,  abortion  will  prob- 
ably occur.  The  discharges  in  the  uterine  cavity  are 
inimical  to  the  spermatozoa,  and  the  diseased  endo- 
metrium furnishes  an  inefficient  place  for  the  attachment 
of  the  ovum. 

Physical  examination  in  a  simple  case  of  chronic  endo- 
metritis shows  a  somewhat  enlarged  uterus,  more  globu- 
lar in  shape  than  normal.  The  fundus  uteri  is  tender 
on  pressure  between  the  vaginal  finger  and  the  abdominal 
hand.     The  external  os  is  usually  patulous. 

Examination  with  the  speculum  shows  the  discharge 
escaping  from  the  external  os.  If  there  is  also  present 
cervical  endometritis,  the  discharge  presents  the  charac- 
teristics of  both  cervical  and  corporeal  mucus.  It  is 
thick  and  tenacious,  puriform,  and  often  streaked  with 
blood.  After  the  cervical  canal  has  been  wiped  out  the 
characteristic  corporeal  discharge  may  appear  unmixed 
with  cervical  mucus.  This  discharge  is  thin,  purulent, 
and  may  be  streaked  with  blood,  or  it  may  be  brownish 
in  color  from  mixture  with  altered  blood. 

If  the  uterus  is  examined  with  the  uterine  sound,  it 
will  be  found  that  the  internal  os  is  patulous;  the  fundus 
is  decidedly  tender  upon  gentle  pressure  with  the  sound, 
and  even  the  gentlest  use  of  the  sound  may  be  followed 
by  bleeding. 

The  patulous  condition  of  the  cervical  canal  and  the 
internal  os  is  a  constant  characteristic  of  all  kinds  of 
gross  disease  in  the  cavitv  of  the  uterus.  The  external  os 
is  usually  patulous  when  the  cervical  mucous  membrane 
is  diseased.  The  external  os,  the  cervical  canal,  and  the 
internal  os  are  open  when  the  corporeal  endometrium  is 
diseased. 

The  only  certain  method  of  making  the  diagnosis  is 
by  the  use  of  the  sharp  uterine  curette,  and  this  instru- 


DISEASES  OF  THE  BODY  OF  THE  UTERUS.    205 

ment  should  always  be  employed  whenever  there  is  even 
the  slightest  suspicion  of  the  possibility  of  malignant  dis- 
ease of  the  endometrium.  The  cervical  canal  is  usually 
sufficiently  open  to  permit  the  use  of  the  curette  without 
dilatation  and  without  an  anesthetic.  Three  or  four  strips 
of  the  endometrium  should  be  removed  from  different 
parts  of  the  uterine  cavity,  and  should  be  submitted  to 
microscopic  examination.  It  is  always  safest  to  perform 
curetting  for  diagnosis  at  the  house  of  the  patient,  and  to 
keep  her  in  bed  for  two  or  three  days  after  the  operation. 
Strict  antisepsis  should  be  observed. 

The  causes  of  chronic  corporeal  endometritis  are  vari- 
ous. Almost  any  disease  of  the  body  of  the  uterus  or  of 
the  cervix  may  eventually  result  in  this  condition;  there- 
fore the  different  causes  of  chronic  endometritis  will  be 
better  appreciated  after  a  discussion  of  diseases  of  the 
uterus.  Laceration  of  the  cervix,  subinvolution,  flexions 
and  versions,  fibroid  tumors,  etc.,  all  produce,  in  time, 
some  form  of  chronic  endometritis. 

Primary  chronic  endometritis  may  result  as  a  later 
stage  of  the  acute  disease,  or  it  may  exist  from  the  be- 
ginning in  the  chronic  form.  .  This  is  especially  true 
of  endometritis  caused  by  gonorrhea.  Here  the  inva- 
sion of  the  disease  is  slow  and  insidious,  and  in  .the 
majority  of  cases  is  preceded  by  no  determinable  acute 
stage. 

Sometimes  endometritis  appears  in  old  women.  Bleed- 
ing from  the  uterus,  purulent  discharge,  and  pain  may  be 
present.  The  condition  is  due  to  the  atrophic  changes 
of  senility  occurring  in  the  endometrium — changes  that 
resemble  those  that  take  place  in  the  mucous  membrane 
of  the  vagina  and  the  external  genitals.  Though  such 
symptoms  may  be  indicative  merely  of  a  benign  condi- 
tion, yet,  as  they  are  also  characteristic  of  the  early  stages 
of  malignant  disease,  they  demand  immediate  thorough 
examination  and  careful  watching. 

Treatment. — As  chronic  endometritis  is  usually  sec- 
ondary to  some  disease  of  the  cervix  or  body  of  the  ute- 


2o6     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

rus,  the  treatment  should  be  directed  toward  the  cure  of 
this  primary  condition. 

The  operation  of  trachelorrhaphy  will  cure  the  subin- 
volution of  the  uterus  and  the  resulting  endometritis. 
Forcible  dilatation  of  the  cervix,  in  the  case  of  an  old 
anteflexion,  will  relieve  the  inflammation  of  the  endo- 
metrium. Correction  of  a  retroversion  will  likewise  re- 
lieve the  resulting  endometritis.  Therefore,  though  in 
every  case  the  cure  may  be  hastened  by  treatment  applied 
directly  to  the  endometrium,  yet  causative  or  complicat- 
ing conditions  must  always  also  be  treated  if  we  wish  the 
cure  to  be  lasting. 

Many  cases  of  mild  endometritis  may  be  relieved  or 
cured  by  attention  to  the  general  hygiene  and  habits  of 
the  woman  and  by  applications  made  only  to  the  vaginal 
aspect  of  the  uterus.  The  dresses  should  be  worn  loose 
about  the  waist  and  supported  from  the  shoulders.  Pro- 
longed standing  and  slow  walking  should  be  avoided. 
Mild  purgation  with  salines  should  be  maintained.  Reg- 
ulated exercise  or  general  massage  should  be  prescribed. 
In  addition,  the  vaginal  douche,  iodine  applications,  and 
the  use  of  the  glycerin  tampon,  with  depletion  from 
puncture  of  the  cervix,  should  be  used,  as  has  already 
been  prescribed  for  the  subinvolution  accompanying 
laceration  of  the  cervix. 

If  these  methods  fail  after  careful  trial,  direct  treat- 
ment must  be  applied  to  the  endometrium. 

The  present  method  of  treating  chronic  corporeal  endo- 
metritis directly  is  by  the  uterine  curette.  Time  is  wasted 
by  the  use  of  applications  to  the  interior  of  the  uterus, 
and  a  great  deal  of  harm  has  resulted  from  such  appli- 
cations carelessly  made. 

The  best  curette  is  the  Sims  sharp  curette  (Fig.  120). 
The  Martin  curette  (Fig.  121)  is  useful  to  remove  the 
endometrium  from  the  fundus. 

The  operation  had  best  be  performed  in  the  menstrual 
interval,  though  it  may  safely  be  performed  during  the 
menstrual  period.     An  anesthetic  should  always  be  ad- 


DISEASES  OF  THE  BODY  OF  THE  UTERUS.    207 

ministered.     The  woman  should  be  placed  in  the  dorso- 
sacral  position,  with  the  feet  in  the  supports.    The  vulva, 


Fig.  120. — Sims's  sharp  curette. 


vagina,    vaginal  cervix,   and   buttocks  should   be   thor- 
oughly sterilized. 

The  anterior  lip  of  the  cervix  should  be  grasped  with  a 


Fig.  121. — Martin's  curette. 

double  tenaculum.  The  cervical  canal  should  be  wiped 
out  with  a  small  sponge  or  with  cotton  and  irrigated  with 
bichloride,  if  the  external  os  is  sufficiently  patulous. 
The  cervical  canal  and  the  internal  os  should  then  be 
dilated  to  about  one  inch.  The  position  of  the  uterus 
should  have  been  previously  determined  by  careful  bi- 
manual palpation. 

The  Sims  curette  should  be  gently  introduced  to  one 
cornu  and  then  drawn  methodically  over  the  whole  of 
the  uterine  surface,  removing  the  endometrium  in  parallel 
strips,  the  length  of  each  strip  being  equal  to  the  distance 
between  the  internal  os  and  the  fundus.  The  curette 
may  be  withdrawn  from  the  uterus  and  washed  in  dis- 
tilled water  as  each  strip  is  removed,  or  withdrawal  and 
washing  may  be  done  after  two  or  three  strips  have  been 
removed.  The  Martin  curette  should  then  be  introduced 
to  one  cornu  and  scraped  over  the  fundus,  as  there  is  usu- 
ally in  this  situation  a  narrow  strip  of  endometrium  that 
is  not  removed  by  the  Sims   curette. 

The  uterus  should  then  be  washed  out  with  warm  dis- 
tilled water  or  with  a  i  :  4000  bichloride  solution.  The 
washing  may  be  done  by  holding  the  cervical  canal  open 
with  the  small  dilator  and  introducing  the  long  tubular 
syringe  nozzle,  or  by  some  form  of  reflux  tube  (Fig.  122). 


2o8     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Opportunity  must  always  be  afforded  for  the  escape  of  the 
irrig^ating  fluid. 

The  operator  should  always  remember  the  danger  of 
perforating  the  uterus  by  the  curette.  This  accident, 
which  has  happened  in  the  hands  of  the  best  surgeons, 
occurs  usually  as  the  instrument  is  introduced,  not  as  it 
is  withdrawn.    It  is  much  more  liable  to  occur  after  labor 


Fig.  122. — Irrigation  of  the  uterus. 

or  recent  abortion,  when  the  uterine  tissues  are  soft,  than 
in  the  conditions  now  under  consideration.  If  perforation 
should  happen,  the  uterus  should  be  carefully  washed  out 
with  the  bichloride  solution,  the  vagina  should  be  lightly 
packed  with  gauze,  and  the  patient  returned  to  bed.  A 
hypodermic  injection  of  ergotin  should  be  administered, 
and  afterward,  when  the  woman  recovers  from  the  an- 
esthetic, small  repeated  doses  of  fluid  extract  of  ergot 
should  be  administered  to  ensure  uterine  contraction.  If 
the  operation  has  been  performed  aseptically,  it  is  prob- 
able that  no  harm  will  result  from  the  accident.  If  peri- 
tonitis should  develop,  celiotomy  must  immediately  be 
performed. 

After  curetting  the  uterus  some  operators  are  in  the 
habit  of  packing  the  uterine  cavity  with  sterile  or  iodo- 
form gauze.  This  procedure  is  liable  to  obstruct  the 
escape,  rather  than  favor  the  drainage,  of  any  discharges 
from  the  cavity  of  the  uterus.  Elevation  of  temperature 
and  uterine  pain  are  often  caused  by  it;  therefore  it  is 
best,  after  the  operation  of  curetting,  merely  to  pack  the 
vagina  lightly  with  sterile  gauze,  which  should  be  re- 
moved in  forty-eight  hours.      Daily  douches  of  a  i  :  4000 


DISEASES  OF  THE  BODY  OF  THE  UTERUS.    209 

bichloride-of-mercury  solution  should  then  be  adminis- 
tered as  long  as  the  woman  remains  in  bed.  The  vagina 
should  be  carefully  dried  after  the  douche,  as  already 
advised. 

Hemorrhage  is  never  profuse  during  curetting,  and 
usually  ceases  after  the  endometrium  has  been  removed 
and  the  uterus  has  been  washed  out. 

In  cases  of  gonorrheal  endometritis  it  is  advisable, 
after  the  uterus  has  been  douched  and  the  bleeding  has 
ceased,  to  apply  carbolic  acid  thoroughly  over  the  whole 

i r      n         it         //     \\    ^ i        \S     W  ' 


if   (J   \\ 


Fig.  123. — Microscopic  section  of  the  normal  endometrium,  showing  the  utricu- 
lar glands  extending  into  the  muscular  tissue  (Beyea). 

interior  of  the  uterus,  because  infection  may  lurk  in  the 
distal  ends  of  the  utricular  glands,  which  are  not  removed 
by  the  curette. 

The  length  of  time  during  which  it  is  advisable  to  keep 
the  woman  in  bed  depends  upon  the  extent  and  nature 
of  the  disease  for  which  the  curetting  has  been  done. 
As  a  general  rule,  the  longer  the  stay  in  bed  the  better 
it  is  for  the  woman.  If  the  uterus  is  much  enlarged  or 
if  subinvolution  is  present,  the  patient  should  stay  in  bed 
for   two  weeks.     Such  rest  in  the   recumbent  position 

14 


2 TO     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

diminishes  the  congestion  of  the  pelvic  organs  and  is  of 
great  aid  in  restoring  the  parts  to  a  normal  condition. 
Careful  attention  should  be  paid  to  the  regularity  of  the 
bowels.  Mild  purgation  with  saline  purgatives  should  be 
contiuued  during  the  convalescence.  Daily  massage, 
started  two  or  three  days  after  the  operation,  will  facili- 
tate the  cure. 

All  the  endometritial  structures  are  never  completely 
removed  by  the  curette.  The  distal  ends  of  the  utricular 
glands,  which  penetrate  the  muscular  coat  of  the  uterus 
(see  Fig.  123),  remain  after  thorough  and  vigorous  curet- 
ting. 

After  removing  the  endometrium  with  the  curette  the 
cavity  of  the  uterus  does  not  become  lined  with  a  cica- 
tricial membrane,  but  a  new  endometrium  is  produced. 
It  is  probable  that  the  new  membrane  is  developed  from 
the  remains  of  the  utricular  glands.  The  new  endo- 
metrium grows  in  a  very  short  time.  In  some  cases  it 
has  been  sufficiently  well  formed  to  permit  pregnancy 
five  weeks  after  curetting. 

The  first  menstrual  period,  and  sometimes  the  second 
and  third,  after  the  operation  of  curetting  may  be  missed. 
As  a  general  rule,  the  menstrual  bleeding  is  much  less 
profuse  than  before  the  operation. 

The  therapeutic  object  of  curetting  for  endometritis  is 
to  replace  the  diseased  endometrium  by  a  new  membrane 
which  has  grown  under  conditions  of  rest  and  asepsis. 

EXFOLIATIVE   ENDOMETRITIS,   OR  MEMBRANOUS   DYS= 
MENORRHEA. 

There  is  a  disease  which  has  been  called  membranous 
dysmenorrhea  or  exfoliative  endometritis,  in  which  large 
membranous  pieces  of  the  endometrium  or  a  cast  of  the 
whole  structure  is  thrown  off"  at  the  menstrual  period 
(see  Fig.  124).  The  condition  is  most  often  found  in  vir- 
gins or  sterile  women.  The  membrane  may  be  thrown 
off  at  every  menstrual  period,  or  at  periods  separated  by 
intervals  of  various  lensfth. 


DISEASES  OF  THE  BODY  OF  THE  UTERUS.    21  J. 


Fig.  124. — Membrane 
charged  in  membranous 
menorrhea. 


dis- 
dys- 


The  menstrual  period  is  usually  accompanied  by  intense 
uterine  pain,  which  may  resemble  labor-pain,  and  which. 

persists  until  the  separation  of 
the  endometrium.  In  some  cases 
of  this  disease  menstruation  is 
very  irregular. 

The  diagnosis  is  made  from  ex- 
amination of  the  characteristic 
membrane  that  is  discharged. 
The  condition  should  not  be 
confused  with  abortion,  in  which 
the  large  irregular  decidual  cells 
will  be  discovered.  Some  wo- 
men are  very  liable  to  early 
menstrual  miscarriage,  and  have 
repeated  accidents  of  this  kind, 
which  in  some  cases  have  led  the 
physician  to  believe  that  the  condition  of  exfoliative  endo- 
metritis was  present. 

The  local  treatment  consists  of  dilatation  and  curet- 
ting of  the  uterus,  which  operation  it  may  be  necessary 
to  repeat  several  times.  Careful  attention  should  be  di- 
rected toward  re-establishing  or  maintaining  the  general 
health. 

SENILE  ENDOMETRITIS. 

This  disease,  also  called  post-climacteric  endometritis, 
occurs  at  any  period  after  the  menopause.  There  is  a 
thin  seropurulent  discharge  from  the  uterus,  often  so  pro- 
fuse as  to  soil  the  clothing.  The  quantity  of  the  dis- 
charge may  be  increased  with  a  certain  monthly  period- 
icity. The  discharge  is  often  streaked  with  blood,  or  is 
brown  colored  from  the  presence  of  altered  blood.  There 
may  be  occasional  or  even  continuous  slight  hemorrhage 
from  the  uterus.  The  discharge  is  usually  fetid,  and  may 
be  exceedingly  irritating  to  the  vagina  and  vulva.  The 
objective  symptoms  often  resemble  in  all  respects  the 
symptoms  of  cancer  of  the  body  of  the  uterus. 


212      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

There  is  usually  dull  pain  in  the  lower  part  of  the 
abdomen  and  the  back;  and  if  the  disease  continues  for 
sufficient  time,  there  may  appear  symptoms  indicative  of 
septic  absorption — loss  of  appetite,  emaciation,  and 
slight  elevation  of  temperature. 

The  pathologic  changes  which  take  place  in  the 
uterus  in  this  disease  have  not  been  definitely  determined. 
It  seems  probable  that  in  some  cases  the  condition  may 
be  produced,  as  in  senile  vaginitis,  by  infection  of  an 
endometrium  the  integrity  of  which  had  been  impaired 
by  the  atrophic  changes  occurring  after  the  menopause. 
Microscopic  examination  of  portions  of  the  endometrium 
removed  by  the  curette  shows  the  appearance  of  long- 
standing chronic  inflammation. 

These  cases  are  often  mistaken  for  cancer  of  the  body 
of  the  uterus,  and  the  diagnosis  should  always  be  imme- 
diately made  by  microscopic  examination  of  the  material 
removed  by  a  thorough  curetting  of  the  whole  of  the 
uterine  cavity. 

The  treatment  of  senile  endometritis  consists  of  appli- 
cations to  the  endometrium  of  a  solution  of  nitrate  of  sil- 
ver, from  one-half  to  one  dram  to  the  ounce  of  water,  or 
of  thorough  curetting  of  the  endometrium. 


CHAPTER  XVIII. 

SUBINVOLUTION   OF  THE  UTERUS;    SUPERINVOLU= 
TION  OF  THE  UTERUS. 

SUBINVOLUTION  OF  THE  UTERUS. 

Subinvolution  of  the  uterus  is  a  condition  that  results 
from  imperfect  involution  of  the  uterus  after  labor,  abor- 
tion, or  miscarriage.  The  muscular  and  fibrous  struc- 
tures of  the  uterus,  which  had  become  hypertrophied 
under  the  influence  of  pregnancy,  fail  to  undergo  prop- 
erly the  retrograde  changes  of  fatty  degeneration  and  ab- 
sorption which  normally  occur  after  the  expulsion  of  the 
product  of  conception,  and  which  are  essential  for  the 
restoration  of  the  uterus  to  its  normal  size.  The  ele- 
ments of  the  endometrium  and  the  vascular  system  of 
the  uterus  also  remain  hypertrophied;  consequently  the 
uterus  is  larger,  heavier,  more  congested  than  normal. 

Similar  arrest  of  involution  may  occur  coincidently  in 
the  ligaments  of  the  uterus,  which  are  left  larger,  longer, 
and  more  relaxed  than  in  the  normal  condition. 

The  pathological  changes  that  occur  in  the  subinvo- 
luted  uterus  are  similar  to  those  found  in  chronic  endo- 
metritis and  metritis,  which  have  already  been  described. 
In  fact,  chronic  endometritis  and  metritis  accompany 
subinvolution  from  the  beginning. 

There  are  many  causes  of  subinvolution  of  the  uterus. 
Too  early  rising  from  bed  is  a  most  frequent  cause.  This 
is  especially  true  after  abortion  or  miscarriage;  for  many 
women  treat  such  occurrences  as  of  but  little  moment, 
and  refuse  to  stay  in  bed  for  more  than  a  few  days. 

Imperfect  evacuation  of  the  uterus  after  abortion  or 
miscarriage  is  a  common  cause.    Laceration  of  the  cervix, 

213 


214      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

retrodisplacement  of  the  uterus,    and  laceration  of  the 
perineum  are  all  causes  of  subinvolution  of  the  uterus. 

The  symptoms  of  subinvolution  are  the  same  as  those 
already  described  under  Chronic  Metritis — backache, 
headache,  bearing-down  pain  in  the  pelvis,  general  phys- 
ical debility,  leucorrhea,  and  menorrhagia. 

The  treatment  of  subinvolution  should  be  directed 
toward  the  relief  of  the  primary  cause  of  the  condition. 
Laceration  of  the  perineum  or  of  the  cervix,  retroversion, 
or  endometritis  caused  by  retention  of  placental  tissue 
after  miscarriage,  should  receive  appropriate  treatment. 

Subinvolution  may  often  be  cured  by  the  douches, 
iodine  applications,  and  depletion  of  the  cervix  spoken 
of  under  the  treatment  of  laceration  of  the  cervix,  pro- 
vided the  primary  cause  is  removed  or  corrected. 

In  any  case  the  cure  is  always  hastened  by  thorough 
curetting  of  the  uterus.  This  operation  should  always 
be  performed  when  the  woman  is  etherized  for  the  relief 
of  any  other  condition,  as  a  laceration  of  the  cervix  or  of 
the  perineum. 

The  cure  of  subinvolution  depends  a  great  deal  upon 
the  time  that  has  elapsed  from  the  inception  of  the  con- 
dition to  the  institution  of  treatment.  The  secondary 
changes  in  the  endometrium  and  body  of  the  uterus 
resulting  from  chronic  congestion  and  inflammation  in 
time  becomes  so  established  that  the  disease  will  not 
yield  to  any  treatment,  even  though  the  primary  cause 
of  the  trouble  may  be  cured. 

In  obstinate  chronic  cases  of  subinvolution  of  the  ute- 
rus amputation  of  the  cervix  sometimes  has  a  most 
marked  effect,  and  this  operation  should  always  be  re- 
sorted to  whenever  the  disease  has  resisted  the  milder 
treatment  already  prescribed.  Amputation  of  the  cervix 
is  sometimes  followed  by  a  transformation  of  all  the  tis- 
sues of  the  uterus  similar  to  that  occurring  in  normal 
involution  after  labor,  and  a  striking  diminution  in  the 
size  of  the  uterine  body  takes  place.  The  amputation 
of  the  cervix  should  always  be  accompanied  by  a  thor- 


SUPERINVOLUTION  OF  THE   UTERUS.         215 

ough  curetting.  Sometimes  the  change  in  the  body  of 
the  uterus  is  so  marked  after  amputation  of  the  cervix, 
or  even  after  trachelorrhaphy,  that  a  condition  of  super- 
involution,  or  uterine  atrophy,  results. 

SUPERINVOLUTION    OF  THE  UTERUS. 

Superinvolution  of  the  uterus  is  a  disease  the  reverse 
of  subinvolution.  In  this  condition  the  uterus,  after 
childbirth  or  abortion,  not  only  undergoes  the  normal 
involution,  but  continues  to  atrophy  until  the  length  of 
the  uterine  cavity  may  measure  but  one  and  a  half  inches. 
The  atrophy  involves  the  neck  as  well  as  the  body  of  the 
organ,  the  Fallopian  tubes,  and  sometimes  the  ovaries. 

Superinvolution  of  the  uterus  is  a  rare  condition.  The 
cause  is  difficult  to  determine.  It  has  been  attributed  to 
great  loss  of  blood  at  confinement,  to  prolonged  lactation, 
and  to  pelvic  peritonitis  occurring  during  the  puerperium. 

Amenorrhea  is  the  most  marked  symptom  of  superin- 
volution. Nervous  disturbances  and  hysterical  symptoms 
may  also  be  present. 

The  diagnosis  is  easily  made  from  the  history  of  the 
case  and  by  means  of  bimanual  examination  and  the  use 
of  the  sound.  Congenital  malformation  may  be  excluded 
from  the  fact  that  a  pregnancy  has  occurred,  and  senile 
atrophy  from  a  consideration  of  the  age  and  history  of 
the  woman.  The  treatment  should  be  directed  to  restor- 
ing and  maintaining  the  general  health  of  the  woman. 

Iron  and  the  remedies  useful  in  other  forms  of  amenor- 
rhea may  be  of  advantage. 


CHAPTER  XIX. 

CANCER  AND    5ARC0MA  OF  THE   UTERUS. 

CANCER  OF  THE   BODY  OF  THE  UTERUS. 

Cancer  of  the  body  of  the  uterus  is  a  rare  disease  in 
comparison  with  cancer  of  the  cervix.  The  older  statis- 
tics— those  of  Schroeder — appear  to  show  that  the  disease 
begins  in  the  body  of  the  uterus  in  about  2  per  cent,  of 


Fig.  125. — Diffuse  cancer  of  the  endometrium. 

all  cases  of  cancer  of  this  organ.  This  percentage,  how- 
ever, is  probably  much  too  small.  Cancer  of  the  body 
of  the  uterus  is  by  no  means  an  infrequent  disease  ;  it  is 
a  disease  for  which  the  physician  should  always  be  on 
the  watch. 

216 


CANCER  AND  SARCOMA  OF  THE  UTERUS.     217 


Cancer  of  the  body  of  the  uterus  originates  in  the  epi- 
thelial structures  of  the  endometrium.  It  may  first  ap- 
pear on  the  surface  of  the  endometrium  or  deeply  in  the 
utricular  glands. 

The  gross  appearance  of  the  disease  varies  as  does 
cancer  of  the  cervix  or  of  any  other  part  of  the  body. 

Cancer  of  the  uterus  may  begin  upon  the  surface  of 
the  endometrium  as  a  superficial  ulceration,  as  a  uniform 
swelling  of  the  mucous  membrane,  as  a  polypoid  or  pap- 
illary projection,  or  as  a  large  cauliflower-like  mass  pro- 
jecting into  the  uterine  cavity. 

When  the  disease  begins  in  the  utricular  glands,  it  may 
form  nodules  throuehout  the  body  of  the  uterus.      These 


Fig.  126. — Nodular  form  of  cancer  of  the  body  of  the  uterus. 

nodules  are  of  various  sizes,  from  that  of  a  pea  to  that  of 
a  hen's  egg.  They  grow  rapidly.  They  may  be  sub- 
mucous and  project  into  the  uterine  cavity,  or  they  may 
project  beneath  the  peritoneal  covering,  giving  the  uterus 
an  irregular  nodular  appearance  (Fig.  126). 

In  the  later  stages  of  the  disease  the  whole  body  of 
the  uterus  becomes  infiltrated.  The  endometrium  is 
destroyed.  The  cancerous  masses  ulcerate  and  break 
down.  The  peritoneal  covering  is  for  a  certain  time  a 
barrier  to  the  extension  of  the  disease.     In  many  cases 


2l8       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

the  whole  of  the  body  of  the  uterus  may  be  infiltrated 
with  cancer,  and  yet  the  peritoneum  will  remain  intact. 
The  accompanying  illustration  (Fig.  127)  shows  this: 
the  infiltration  extends  to,  but  does  not  involve,  the  peri- 
toneum. 

Later,  however,  the  peritoneum,  the  Fallopian  tubeSj 
and  the  ovaries  become  involved.      Intestinal  adhesions 


Fig.  127. — Cancer  of  the  body  of  the  uterus:  a  large  single  cancerous  nodule 
[c)  in  the  anterior  wall  has  been  divided. 

are  formed,  and  the  disease  may  extend  throughout  the 
abdominal  cavity.  The  cervix  and  the  vagina  may  be 
attacked  by  extension  from  above,  though,  on  the  other 
hand,  the  disease  may  progress  sufficiently  to  destroy 
life,  and  yet  the  cervix  may  remain  unaffected. 

Metastasis  may  take  place  by  way  of  the  lymphatics. 
Extension  by  metastasis,  however,  is  unusual. 

Cancer  of  the  body  of  the  uterus  occurs  at  a  somewhat 
later  age  than  cancer  of  the  cervix.  The  average  age  is 
between  fifty  and  sixty.  The  disease  attacks  both  the 
parous  and  nulliparous  woman,  the  latter  perhaps  more 
often  than  the  former. 


CANCER  AND  SARCOMA  OF  THE  UTERUS.     219 

The  causes  of  cancer  of  the  body  of  the  uterus  are 
unknown.  It  is  probable  that  the  various  forms  of  endo- 
metritis, by  diminishing  the  resistance  of  the  endo- 
metrium, predispose  to  the  development  of  cancer.  It 
has  been  maintained  that  fibroid  tumors  of  the  uterus,  as 
a  result  of  the  accompanying  alterations  in  the  endo- 
metrium, predispose  to  cancer.  Cancer  of  the  endo- 
metrium is  certainly  not  infrequently  found  in  uteri  con- 
taining fibroid  tumors. 


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Fig.  128. — Malignant  adenoma  of  the  body  of  the  uterus  (Beyea). 

Malignant  adenoma  is  a  disease  of  the  utricular  glands 
which  has  been  classed  by  some  writers  as  a  distinct  dis- 
ease, by  others  as  a  form  of  carcinoma.  In  it  the  gland- 
spaces  are  much  enlarged,  irregular,  and  joined  to  other 
gland-spaces.  The  columnar  epithelial  cells  often  fill 
the   whole   of  the   gland-space   (Fig.    128).     The    cells, 


220      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

however,  never  infiltrate  the  interstitial  tissue,  as  in 
cancer.  The  muscular  wall  of  the  uterus  appears  to  be 
destroyed  by  atrophy  or  by  fatty  degeneration. 

The  disease  is  malignant,  it  extends  to  the  neighboring 
structures,  and  it  destroys  life.  It  presents,  at  any  rate 
in  the  later  stages,  all  the  gross  appearances  and  phe- 
nomena of  cancer. 

The  symptoms  of  cancer  of  the  fundus  are  hemor- 
rhage,  leucorrheal  discharge,  and  pain. 


Fig.  129. — Advanced  malignant  adenoma  of  the  body  of  the  uterus.    A  fibroid 
tumor  (7^)  is  in  the  fundus. 

In  women  before  the  time  of  the  menopause  the  hemor- 
rhage may  appear  as  a  menorrhagia  or  a  metrorrhagia, 
as  an  increase  of  the  normal  menstrual  bleeding,  or  as  a 
bleeding  occurring  at  some  other  time  than  the  normal 
menstrual  period.  Such  irregular  bleeding  may  be  caused 
by  any  unusual  effort. 

After  the  menopause  the  hemorrhage  may  appear  as  a 


CANCER  AND  SARCOMA  OF  THE  UTERUS.     221 

return  of  menstruation,  occurring  with  more  or  less 
periodicity,  and,  as  in  cancer  of  the  cervix,  often  con- 
templated with  satisfaction  by  the  woman.  It  may  ap- 
pear as  a  slight  occasional  discharge  of  blood,  as  a  bloody 
streak  in  the  leucorrheal  discharge,  as  a  spot  upon  the 
clothing,  or  as  continuous  hemorrhage.  In  the  late 
stages  of  the  disease  there  is  a  continuous  discharge  of 
blood. 

The  leucorrheal  discharge  at  first  resembles  that  of  a 
non-malignant  endometritis.  It  often  begins  as  a  grad- 
ual increase  of  a  leucorrhea  which  the  woman  may  have 
had  for  several  years.  It  may  be  streaked  with  blood. 
In  the  early  stages  there  is  nothing  at  all  characteristic 
about  the  discharge;  later,  however,  it  usually  becomes 
very  offensive,  on  account  of  the  breaking  down  of 
necrotic  tissue.  It  becomes  more  purulent  in  character, 
and  brown  in  color  from  the  presence  of  blood.  In  some 
cases  of  cancer  of  the  fundus,  however,  the  leucorrheal 
discharge  remains  light-colored  and  practically  odorless 
throughout  the  whole  course  of  the  disease.  It  is  some- 
times thin  and  watery  and  exceedingly  profuse,  saturating 
many  napkins  during  the  day. 

The  pain  of  cancer  of  the  fundus  is  not  a  marked 
symptom.  It  may  be  absent  even  though  the  whole 
body  of  the  uterus  be  involved  by  the  disease.  When 
the  peritoneum  is  affected,  and  extension  takes  place  to 
other  pelvic  structures,  the  pain  is  much  more  pro- 
nounced. In  other  cases  the  pain  may  be  present  in  the 
early  stages,  before  the  disease  has  extended  beyond  the 
endometrium. 

The  pain  may  be  referred  to  the  region  of  the  uterus, 
to  the  back,  or  sometimes  to  parts  of  the  pelvis  remote 
from  the  uterus,  as  the  crest  of  the  ilium. 

Bimanual  examination  shows  a  patulous  external  os, 
cervical  canal,  and  internal  os.  As  has  already  been 
said,  this  patulous  condition  is  characteristic  of  gross 
disease  of  the  endometrium. 

The  body  of  the  uterus  is  usually  somewhat  enlarged^ 


222       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

tender  on  pressure  between  the  vaginal  finger  and  the 
abdominal  hand,  and,  in  the  late  stages  of  the  nodular 
form  of  cancer,  irregular  in  outline. 

The  causes  of  death  in  cancer  of  the  fundus  uteri  are 
the  same  as  those  that  have  already  been  considered  in 
cancer  of  the  cervix.  Extension  to  abdominal  organs  is, 
however,  more  frequent  in  cancer  of  the  fundus. 

Diagfnosis. — It  is  of  the  greatest  importance  to  make 
an  early  diagnosis  of  cancer  of  the  fundus  uteri,  because, 
of  all  parts  of  the  body  that  may  be  attacked  by  malig- 
nant disease,  the  fundus  uteri  offers  the  best  prospect  of 
cure  by  operation.  In  the  early  stages  the  disease  can 
easily  be  completely  removed. 

Hemorrhage  from  the  uterus  is  the  universal  symptom, 
and  should  never  be  disregarded.  The  various  manifes- 
tations of  hemorrhage  in  cancer  of  the  fundus  should 
always  be  borne  in  mind,  and  should  always  prompt  a 
thorough  investigation. 

Ivcucorrheal  discharge  occurring  at  or  after  the  men- 
opause, in  a  woman  previously  free  from  such  discharge, 
should  also  excite  suspicion. 

If  a  careful  examination  of  the  cervix  fails  to  reveal 
any  cause  for  the  hemorrhage  or  the  discharge,  the  inte- 
rior of  the  uterus  should  be  thoroughly  examined  by  the 
curette. 

A  patulous  cervical  canal  and  internal  os  are  good  indi- 
cations that  there  is  some  gross  disease  of  the  endome- 
trium. In  cancer  of  the  fundus  the  cervical  canal  and 
the  internal  os  are  usually  sufficiently  open  to  permit 
thorough  curetting  without  further  dilatation. 

The  Sims  sharp  curette  may  be  used  with  safety  if 
ordinar}^  care  be  observed.  If  the  woman  is  nervous,  an 
anesthetic  should  be  administered,  though  in  most  cases 
diagnostic  curetting  gives  but  little  pain  and  may  be  per- 
formed without  ether. 

The  operator  should  not  be  content  with  the  removal 
of  a  few  strips  or  portions  of  the  endometrium.  He 
should  remember  that  in  the  early  stages  the  disease  may 


CANCER  AND  SARCOMA  OF  THE  UTERUS.     223 

be  confined  to  a  small  area,  and,  unless  the  whole  interior 
of  the  uterus  is  gone  over,  this  area  may  be  missed  by 
the  curette,  and  only  healthy  endometrium  may  be  re- 
moved for  examination.  Such  thorough  curetting  is  of 
especial  importance  in  case  the  tissue  removed  should  at 
first  present  no  suspicious  features  upon  gross  examina- 
tion. All  portions  of  the  endometrium  should  be  saved 
and  preserved  as  directed  in  cancer  of  the  cervix. 

The  tissue  should  be  submitted  for  examination  to  a 
person  trained  in  gynecological  pathology.  The  recog- 
nition of  the  early  stages  of  cancer  of  the  endometrium, 
and  especially  of  malignant  adenoma,  requires  the  train- 
ing of  the  expert.  If  a  positive  diagnosis  cannot  be 
given  from  the  microscopic  examination,  the  case  should 
be  carefully  watched,  and  if  the  symptoms  continue, 
subsequent  curetting  and  microscopic  examination  should 
be  made. 

The  treatment  of  cancer  of  the  fundus  is  immediate 
complete  hysterectomy,  with  removal  of  the  tubes  and 
ovaries.  Cancer  has  recurred  in  an  ovary  after  removal 
■of  the  uterus.  The  hysterectomy  may  be  performed  by 
the  vaginal,  the  abdominal,  or  the  combined  method. 

The  ultimate  results  of  hysterectomy  for  cancer  of  the 
body  of  the  uterus  are  exceedingly  good.  Recurrence 
may  be  considered  exceptional.  In  this  respect  they  are 
in  marked  contrast  to  the  results  after  operation  for  can- 
cer of  the  cervix. 

SARCOMA  OF  THE   UTERUS. 

Sarcoma  of  the  uterus  is  a  very  rare  disease.  There 
bave  been  but  few  properly  authenticated  cases  of  this 
disease  reported  in  medical  literature.  All  cases  of  this 
disease  should  be  put  on  record. 

There  are  two  varieties  of  sarcoma  of  the  uterus:  dif- 
fuse sarcoma  of  the  mucous  membrane,  and  sarcoma  of 
the  uterine  parenchyma. 

In  diflEuse  sarcoma  of  the  mucous  membrane  the 
endometrium    is   infiltrated   by    round    or   spindle   cells. 


224     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Soft  projections  or  tumors,  which  may  be  villous,  lob- 
ulated,  or  polypoid  in  shape,  are  formed  upon  the  mucous 
membrane. 

'The  polypoid  sarcoma  may  present  at  the  cervix  uteri. 
The  disease  extends  to  the  muscular  coat  of  the  uterus. 


Fig.  I^O. — Diffuse  sarcoma  of  the  mucous  membrane  of  the  uterus. 


In  the  later  stages  ulceration  and  disintegration  of  tis- 
sue occur. 

The  cervix  is  not  involved  by  the  disease. 

The  symptoms  of  this  form  of  sarcoma  resemble  those 
of  cancer  of  the  fundus.  There  are  hemorrhage,  dis- 
charge, and  pain. 

The  discharge  is  serous,  and  is  less  fetid  than  in  cancer, 
as  ulceration  takes  place  later  in  the  course  of  the  disease. 

The  cervical  canal  is  patulous,  and  in  the  polypoid 
form  the  tumor  may  be  felt  projecting  into  the  cavity  of 
the  uterus  or  protruding  from  the  external  os. 

The  fundus  uteri  is  enlarged  and  is  tender  upon  pres- 


CANCER  AND  SARCOMA  OF  THE  UTERUS.    225 

sure.     A  positive  diagnosis  can  be  made  only  by  micro- 
scopic examination  of  curetted  or  excised  tissue. 

Sarcoma  of  the  uterine  parenchyma,  or  fibro-sar- 
coma,  or  recurrent  fibroid,  begins  in  the  muscular  coat  of 
the  uterus.  It  appears  as  nodules  of  various  size,  which 
may  be  interstitial  or  confined  to  the  muscular  coat,  sub- 
mucous .or  projecting  beneath  the  mucous  membrane,  or 
subperitoneal,  projecting  beneath  the  peritoneal  coat. 
On  section  these  nodules  are  pale  in  appearance  and  soft 
in  consistency.  They  are  rarely  found  in  the  cervix. 
The  submucous  form  of  nodule  may  become  polypoid, 
project  into  the  cavity  of  the  uterus,  and  with  compara- 
tive frequency  produce  inversion  of  the  uterus. 

The  nodules  of  sarcoma  differ  from  those  of  benign 
fibroid  tumors  in  the  fact  that  they  have  no  capsule. 
They  cannot  be  enucleated,  but  are  intimately  connected 
with  the  surrounding  uterine  tissue.  Metastatic  nodules 
occur  in  the  vagina,  the  peritoneum,  and  in  other  parts 
of  the  body. 

In  the  later  stages  of  the  disease  the  nodules  disin- 
tegrate and  break  down. 

It  is  probable  that  fibro-sarcoma  usually,  if  not  always, 
originates  in  a  benign  fibroid  tumor.  In  the  early  stage 
of  the  disease  the  microscopic,  appearances  of  fibroid 
tumor  are  present,  and  the  transition  from  the  benign  to 
the  malignant  growth  may  be  studied. 

Symptoms. — The  symptoms  of  this  form  of  sarcoma 
resemble  at  first  those  of  fibiroid  tumor;  they  are — hemor- 
rhage in  the  form  of  menorrhagia;  a  serous,  non-odorous 
discharge;  and  a  moderate  degree  of  pain. 

Later,  when  ulceration  and  disintegration  take  place, 
the  hemorrhage  becomes  more  profuse  and  continuous. 
The  discharge  becomes  fetid,  and  contains  broken-down 
sarcomatous  tissue.  The  pain  becomes  more  severe. 
The  uterus  is  enlarged,  and  the  nodular  outline  may  be 
determined  by  palpation. 

Before  metastasis  has  taken  place  the.  differential  diag- 
nosis between  sarcoma  and  benign  fibroid  tumor  can  be 

15 


226     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

made  only  by  microscopic  examination  of  the  discharge 
or  of  curetted  or  excised  portions  of  tissue.  The  dura- 
tion of  sarcoma  of  the  uterus  is  about  three  years. 

Sarcoma  may  occur  at  ahnost  any  age.  Hysterectomy 
has  been  performed  for  this  disease  in  a  girl  of  thirteen. 
Several  cases  have  been  reported  under  twenty  years  of 
age.  The  most  usual  period  is  about  the  time  of  the 
menopause,  in  the  decade  from  forty  to  fifty. 

The  treatment  of  sarcoma  of  the  uterus  is  immediate 
complete  hysterectomy.  If  in  the  early  stage  a  positive 
diagnosis  cannot  be  made  between  benign  fibroid  and 
sarcoma,  the  woman  should  not  be  exposed  to  the  dan- 
gers of  waiting,  but  the  uterus  should  be  immediately 
removed. 


CHAPTER   XX. 
FIBROID  TUMORS  OF  THE  UTERUS. 

Fibroid  tumors  originate  in  the  muscular  wall  of  the 
uterus.  They  are  composed  of  elements  resembling,  to 
a  greater  or  less  extent,  those  that  compose  the  middle 
uterine  wall.  They  consist  of  connective  tissue  and  of 
unstriped  muscular  tissue  in  varying  proportions.  Uterine 
tumors  composed  exclusively  of  muscular  fibres — true 
myomata — very  rarely  occur. 

A  number  of  names,  based  upon  the  proportion  of  the 
component  elements,  have  been  used  by  writers  to  desig- 
nate these  tumors.  They  have  been  called  fibroma,  my- 
oma, myo-fibroma,  and  fibro-myoma.  The  natural  his- 
tory of  all  the  varieties  is  about  the  same,  and  varies  but 
little  with  the  proportion  of  the  elements.  I  shall  there- 
fore consider  them  under  the  general  name  of  fibroid 
tumors  of  the  uterus. 

Fibroid  tumors  of  the  uterus  are  benign,  in  the  sense 
that  they  do  not,  like  cancer,  infiltrate  contiguous  struc- 
tures or  infect  the  general  system. 

Fibroid  tumors  are  loosely  attached  to  the  surrounding 
uterine  wall.  They  are  usually  invested  by  loose  cellular 
tissue,  forming  a  capsule  from  which  they  may  easily  be 
enucleated.  Blood-vessels,  usually  of  small  size,  connect 
the  tumor  with  its  capsule.  Dense  adhesion  between  the 
tumor  and  its  capsule  is  the  result  of  inflammatory 
action.  The  loose  connection  of  the  fibroid  tumor  with 
the  surrounding  structures  explains  the  ease  with  which 
these  tumors  travel  and  are  squeezed  out  of  the  uterine 

227 


228     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


Fig.  131. — Interstitial  fibroid  tumor  of  the  uterus.     A  small  submucous  fibroid 
appears  in  the  uterine  cavity. 


Fig.  132. — Subperitoneal  fibroid  tumors  of  the  uterus. 


FIBROID  TUMORS  OF  THE  UTERUS.  229 

wall.      It  \Yill  be    remembered  that   in  this   respect  the 
fibroid  differs  from  the  nodule  of  cancer  and  of  sarcoma. 

To  the  naked  eye  fibroid  tumors  present  a  white  or 
rosy  appearance.  The  intensity  of  the  red  color  is,  as 
a  rule,  proportional  to  the  amount  of  muscular  tissue. 
On  section  the  bundles  of  fibrous  tissue,  arranged  more 
or  less  concentrically  about  many  axes,  may  be  apparent. 
The  vessels  in  the  tumor  itself  are  usually  small  and  few 
in  number.  The  large  arteries  and  venous  sinuses  are 
found  in  the  capsule. 

Fibroid  tumors  vary  in  hardness  from  the  soft  myoma 
to  dense  stony  nodules  composed  almost  entirely  of  fibroid 
tissue. 

Fibroid  tumors  vary  in  size  from  the  smallest  nodule 
in  the  uterine  wall  to  a  solid  mass  weighing  one  hundred 
and  forty  pounds.  The  tumors  that  usually  come  under 
observation  weigh  from  one  to  ten  pounds. 

Fibroid  tumors  occur  most  frequently  in  the  body  of 
the  uterus.  xA.s  has  already  been  mentioned,  however, 
they  are  sometimes  found  in  the  infra-vaginal  portion  of 
the  cervnx,  and  a  peculiarly  dangerous  form  of  fibroid 
grows  from  the  supra-vaginal  cer^'ix. 

Fibroid  tumors  are  multiple  in  the  great  majority  of 
cases.  It  is  unusual  to  find  a  single  fibroid  nodule  or 
tumor  in  the  uterus.  Sometimes  one  tumor  far  outgrows 
the  rest,  but  if  the  uterine  wall  is  carefully  examined 
other  small  nodules  will  usually  be  found  in  its  sub- 
stance. 

Fibroid  tumors  originate  in  the  muscular  wall  of  the 
uterus,  and  extend  thence  in  various  directions.  When 
they  are  situated  in  the  muscular  wall  they  are  said  to  be 
interstitial  (Fig.  131).  When  they  grow  outward,  so  that 
they  project  beneath  the  peritoneum,  they  are  called  sub- 
peritoneal CFig.  132').  When  they  project  into  the  ute- 
rine cavity  they  are  called  submucous  (see  Fig.    131). 

When  they  grow  from  the  side  of  the  uterus,  and  espe- 
cially from  the  supra-vaginal  portion  of  the  cervix,  and 
extend  outward  into  the  cellular  tissue  between  the  folds 


230     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

of  the  broad  ligaments,  they  are  said  to  be   intra-liga- 
mentous  (Fig.  133). 

The  subperitoneal  fibroid  vi\d.y  continue  to  grow,  push- 
ing the  peritoneum  ahead  of  it,  until  the  tumor  becomes 
altogether  extruded  from  the  body  of  the  uterus.  It  is 
then  attached  to  the  uterus  only  by  a  pedicle  of  varying 
thickness.     The  pedicle  may  be  fibro-muscular  in  cha- 


FlG.  133. — Subperitoneal  fibroids  and  an  intra-ligamentous  fibroid  of  the  uterus. 

racter,  or  it  may  consist  only  of  peritoneum,  a  little  mus- 
cular tissue,  and  blood-vessels. 

Such  a  hard,  freely  movable  tumor  often  causes  a  great 
deal  of  peritoneal  irritation.  A  serous  fluid  may  be 
thrown  out  by  the  peritoneum,  and  a  moderate  degree  of 
ascites  may  occur.  Adhesions  may  be  formed  between 
the  fibroid  tumor  and  contiguous  structures — the  abdom- 
inal parietes,  the  omentum,  or  intestines.  These  adhe- 
sions are  often  exceedingly  extensive,  firm,  and  vascular, 
so  that  in  some  cases  the  tumor  derives  its  chief  blood- 
supply  and  mechanical  support  from  such  adventitious 
attachments.  The  uterine  pedicle  may,  as  a  result  of 
progressive  atrophy,  traction,  or  violence  from  a  fall,  be- 
come detached,  and  the  tumor,  having  then  lost  all  ute- 
rine connection,   appears  to  be  a  fibroid  growth  of  the 


FIBROID  TUMORS  OF  THE  UTERUS.  231 

omentum,  intestine,  or  abdominal  wall.  This  is  the 
origin  of  many  so-called  fibroid  tumors  of  these  struc- 
tures. 

Detachment  from  the  uterus  may  also  occur,  as  the 
result  of  atrophy  of  the  pedicle  or  of  violence,  in  the 
case  of  a  pediculated  subperitoneal  fibroid  that  has  not 
contracted  adhesions  to  other  structures,  and  the  tumor 
will  then  be  found  free  in  the  abdominal  cavity. 

The  subperitoneal  fibroid  in  its  upward  growth  some- 
times drags  the  body  of  the  uterus  with  it,  and  in  this 
way  may  produce  great  elongation  and  distortion  of  the 
cervix. 

772^  stibmiicoiis  fibroid  grows  toward  the  uterine  cavity. 
It  presses  the  mucous  membrane  before  it,  and  it  may 
enter  the  cavity  of  the  uterus,  being  altogether  extruded 
from  the  uterine  wall.  It  then  forms  a  pediculated  tumor 
lying  in  the  uterus — an  intra-uterine  polyp.  The  pedicle 
is  composed  of  dense  fibro-muscular  tissue,  and  is  in- 
vested by  a  sheath  of  mucous  membrane,  unless  this 
structure  has  been  destroyed.  The  pedicle  may  be  but 
slightly  vascular,  or  it  may  rarely  contain  large  arteries. 
As  a  general  rule,  the  greater  the  degree  of  the  extrusion 
of  the  polyp  and  the  longer  the  pedicle,  the  less  is  the  vas- 
cular supply.  Rapid  spontaneous  hemostasis  occurs  after 
a  fibroid  polyp  is  cut  from  its  pedicle,  as  a  result  of  the 
thickness  of  the  arterial  walls  and  the  contractility  of 
the  pedicle. 

The  intra-uterine  polyp,  from  prolonged  pressure,  some- 
times acquires  the  shape  of  the  uterine  cavity. 

Uterine  contractions  are  excited  by  the  presence  of  the 
polyp,  and  the  tumor  may  in  time  be  expelled  from  the 
uterus,  enter  the  vagina,  and  protrude  at  the  vulva. 

Submucous  fibroids  form  the  most  usual  variety  of 
uterine  polypi.  In  some  cases  the  overlying  mucous 
membrane  becomes  much  stretched  and  attenuated,  and 
may  finally  rupture  or  slough.  The  fibroid  tumor  may 
then  escape  through  the  opening  in  the  mucous  mem- 
brane, and,   having  been  extruded  altogether  from   the 


232      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

uterine  wall,  may  be  expelled  from  the  body  by  uterine 
contractions. 

The  fibroid  polyp,  being  exposed  to  septic  influences 
from  the  vagina,  may  become  inflamed  and  suppurate;  or 
sloughing  and  disintegration  may  occur  because  of  inter- 
ference with  the  blood-supply  in  the  pedicle. 

The  intra-ligamentous  fibroid  grows  from  the  side  of  the 
uterus  or  from  the  supra-vaginal  cervix.  It  pushes  apart 
the  peritoneal  folds  of  the  broad  ligament,  and  grows  be- 
tween them  or  beneath  them.  The  tumor  is  thus  out- 
side of  the  peritoneum.  It  may  fill  the  whole  pelvis 
with  a  dense  unyielding  mass,  pushing  the  uterus  to  the 
pelvic  wall,  destroying  anatomical  relations,  and  exerting 
most  disastrous  pressure  upon  blood-vessels,  nerves, 
ureters,  and  other  pelvic  structures. 

Sometimes,  as  these  tumors  enlarge  in  an  upward  di- 
rection, they  .carry  with  them  overlying  pelvic  organs; 
thus  the  ureter  may  be  found  passing  over  the  top  of  a 
tumor  which,  beginning  as  an  intra-ligamentous  pelvic 
growth,  has  become  abdominal. 

In  some  cases  the  fibroid  grows  from  the  posterior  as- 
pect of  the  supra-vaginal  cervix,  passes  beneath  the 
bottom  of  Douglas's  pouch,  pushes  the  peritoneum  above 
it,  and  becomes  a  retro-peritoneal  tumor. 

Again,  it  may  grow  from  the  anterior  aspect  of  the  cer- 
vix in  the  vesico-uterine  space,  and  as  it  extends  upward 
may  push  the  vesico-uterine  fold  of  peritoneum  above  it 
and  drag  up  the  bladder,  so  that  this  viscus  is  sometimes 
found  spread  out  upon  the  anterior  face  of  the  tumor  and 
extending  as  high  as  the  umbilicus. 

As  has  already  been  said,  fibroid  tumors  are  usually 
multiple,  and  if  one  of  the  terms  designating  the  position 
of  the  tumor  as  subperitoneal  or  intra-ligamentous  is 
used  to  describe  any  case,  we  understand  that  the  chief 
tumor-mass  is  of  this  character. 

The  fibroid  polyp  is  more  likely  to  be  single  than  any 
of  the  other  varieties.  In  fact,  the  fibroid  polyp  is  usu- 
ally single;  that  is,  no  other  fibroid  tumor  can  be  detected 


FIBROID  TUMORS  OF  THE  UTERUS.  233 

in  the  body  of  the  uterus.  This  is  not  always  the  case, 
however,  and  sometimes  the  repeated  expulsion  of  suc- 
cessive fibroid  polypi  from  the  same  woman  renders  it 
probable  that  several  nodules  were  simultaneously  pres- 
ent in  the  uterine  wall. 

As  a  rule,  fibroid  tumors  of  the  uterus  are  of  slow 
growth.  In  some  cases  five,  ten,  or  fifteen  years  may 
elapse  before  the  tumor  attains  the  size  of  the  fetal  or  the 
adult  head.  Sometimes  the  tumor  appears  to  be  of  lim- 
ited growth,  and  early  attains  its  maximum  size,  or  it 
may  not  increase  at  all  in  size  after  its  first  discovery  by 
the  woman;  in  other  cases  the  tumor  slowly  but  steadily 
grows  until,  after  a  lapse  of  ten  or  twenty  years,  it  fills 
the  whole  of  the  abdominal  cavity  and  renders  the  woman 
helpless  from  weight  and  pressure;  and,  finally,  in  some 
instances  the  tumor  grows  unlimitedly  with  the  rapidity 
.characteristic  of  an  ovarian  cyst,  and  in  one  or  two  years 
may  crowd  the  woman  out  of  existence.  This  rapid  un- 
limited growth  is  characteristic  of  tumors  of  the  fibro- 
cystic variety. 

A  fibroid  tumor  causes  very  marked  changes  in  the 
body  of  the  uterus — the  muscular  coat  and  the  endome- 
trium. The  whole  uterus  becomes  enlarged.  The  cavity 
is  increased  in  length,  and  the  muscular  wall  becomes 
often  very  much  hypertrophied.  This  hypertrophy  re- 
sembles that  occurring  in  pregnancy.  Even  small  fibroid 
tumors  may  produce  this  condition,  which  seems  to  de- 
pend more  upon  the  position  than  upon  the  size  of  the 
growth.  The  interstitial  and  the  submucous  tumors  are 
accompanied  by  a  greater  degree  of  uterine  hypertrophy 
than  accompanies  the  subperitoneal  growths.  In  some 
cases  the  uterus  may  be  of  normal  size  if  the  subperito- 
neal growth  has  become  pedunculated.  The  uterus  may 
appear  to  be  uniformly  enlarged  to  the  size  of  the  fourth 
or  fifth  month  of  pregnancy,  and  when  incised  it  will  be 
found  to  contain  one  or  more  interstitial  or  subperitoneal 
tumors  that  have  become  encapsulated  by  it.  When  such 
a  case  is  subjected  to  celiotomy  the  resemblance  of  the 


234     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Uterus  to  pregnancy  is  very  striking.  Between  such  a 
smooth,  uniformly  enlarged  uterus  on  the  one  hand,  and 
the  irregular,  distorted  mass  of  subperitoneal  fibroids  on 
the  other,  there  are  an  infinite  number  of  varieties.  A 
great  increase  in  the  vascular  supply  accompanies  the  hy- 
pertrophy of  the  uterus.  The  ovarian  and  uterine  arteries 
and  their  branches  become  very  much  hypertrophied, 
while  the  veins  in  the  broad  ligaments  and  the  sinuses 
in  the  capsule  of  the  tumor  become  enormous. 

The  endometrium  shares  in  the  changes  that  take  place 
in  the  uterus.  It  is,  of  course,  increased  in  area  with 
the  increase  of  the  uterine  cavity.  There  may  be  atro- 
phic changes  from  pressure  upon  or  tension  of  this  mem- 
brane, or  various  forms  of  endometritis  may  be  present, 
most  usually  the  interstitial  and  the  glandular.  The 
glandular  form  of  the  disease  is  said  to  occur  most  fre- 
quently when  the  tumor  is  remote  from  the  cavity  of  the 
uterus,  as  in  the  subperitoneal  variety;  while  interstitial 
endometritis  occurs  with  the  submucous  and  the  inter- 
stitial tumors. 

In  the  Fallopian  tubes  and  the  ovaries  pathological 
changes  occur  as  the  result  of  uterine  fibroids.  The 
tubes  may  present  any  of  the  forms  of  cystic  change — 
hydrosalpinx,  p^'osalpinx,  or  hematosalpinx — that  are 
caused  by  salpingitis.  It  is  probable  that  these  diseases 
are  often  caused  by  extension  of  endometritis.  The  tubes 
and  ovaries  may  be  much  distorted  and  displaced  from 
the  normal  position.  In  some  cases  the  ovary  is  drawn 
out  into  a  long  cord  five  inches  in  length ;  in  other  cases 
it  is  spread  out  upon  the  face  of  the  tumor. 

Fibroid  tumors  are  liable  to  several  forms  of  degenera- 
tion— calcareous,  fatt}-,  myxomatous,  edematous,  cystic, 
telangiectatic,  gangrenous  or  suppurative,  and  malig- 
nant. 

Calcareous  change^  from  the  deposit  of  lime-salts  in 
the  fibroid  nodules,  is  an  unusual  occurrence.  It  appears 
most  often  in  women  beyond  the  menopause,  and  is  part 
of  the  atrophic  changes  that  take  place  at  this  time.     (It 


FIBROID  TUMORS  OF  THE  UTERUS.  235 

has  occurred  in  a  woman  who  had  been  subjected  to 
oophorectomy  for  the  relief  of  a  fibroid  tumor.) 

I  have  seen  a  fibroid  tumor  the  size  of  the  adult  head 
— a  solid  calcareous  mass  which  could  be  divided  only 
by  means  of  a  saw. 

The  calcareous  nodules  are  surrounded  by  uterine  tissue 
to  which  they  are  but  loosely  attached.  They  may  be 
forced  out  of  the  uterus  and  escape  at  the  vulva.  They 
have  been  called  "womb-stones." 

Fatty  degene7'-ation  is  a  very  unusual  condition.  It  has 
been  assumed  to  take  place,  as  a  step  preliminary  to  ab- 
sorption, in  those  cases  in  which  a  fibroid  tumor  dis- 
appears after  labor  or  from  other  cause. 

Myxomatous  degeneration  is  also  rare.  In  it  an  effusion 
of  mucous  fluid  takes  place  between  the  bundles  of  fibrous 
tissue.     Sometimes  large  cavities  are  formed  in  this  way. 

In  the  edematous  Jibroid  the  whole  tumor  is  permeated 
by  a  serous  fluid.  This  condition  is  not  unusual.  It 
resembles  edema  in  any  other  part  of  the  body.  It  is 
often  found  in  young  women  before  the  thirtieth  year. 

Cystic  degeneration  of  fibroid  tumors  may  result  from 
any  of  the  forms  of  degeneration  with  softening  in  which 
cystic  cavities  are  formed. 

In  some  q.3>.s^s  fibro-cystic  tumors  are  caused  by  dilata- 
tion of  the  lymphatics.  They  have  been  called  "  lym- 
phangiectatic  fibroids."  An  endothelial  lining  has  occa- 
sionally been  found  in  the  cystic  cavities  of  these  tumors. 
The  fluid  removed  from  the  cyst-cavities  coagulates  spon- 
taneously. Such  fibroids  have  frequently  been  mistaken 
for  ovarian  cysts. 

In  the  telangiectatic  or  the  cavernozis  form  of  fibroid 
tumor  there  is  an  enormous  dilatation  of  the  vessels  in 
the  new  growth.  The  venous  spaces  are  sometimes  as 
large  as  a  walnut,  and  are  filled  with  clotted  or  fluid 
blood.  This  change  usually  affects  one  part,  and  not  all, 
of  the  tumor,  which  presents  the  gross  appearance  of  a 
sponge  soaked  with  blood. 

Gangrene  is  most  liable  to  occur  in  the  fibroid  polyp. 


236     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

During  the  process  of  expulsion  from  the  uterus  the  vas- 
cular supply  through  the  pedicle  becomes  impeded,  so 
that  there  is  not  sufficient  blood  for  nutrition.  The 
tumor  is  exposed  to  septic  infection  through  the  vagina 
and  the  cervix,  and  sloughing  and  suppuration  occur.  As 
a  result  of  such  disintegration  the  tumor  may  be  dis- 
charged piecemeal. 

Iiifiamniation.,  and  occasionally  suppuration.,  of  fibroid 
tumors  remote  from  the  cavity  of  the  uterus  may  occur 
from  infection  through  the  intestinal  tract  or  other 
channel. 

Sarcoma  may  develop  in  a  fibroid  tumor  of  the  uterus. 
As  has  already  been  stated,  the  "circumscribed  fibroid 
sarcoma,"  or  sarcoma  of  the  uterine  parenchyma,  is 
thought  by  some  authorities  always  to  originate  from 
degeneration  of  a  benign  fibroid  tumor.  It  seems  prob- 
able that  the  fibroid  tumor  predisposes  the  woman  to  the 
development  of  sarcoma  of  the  uterus. 

Cancer  may  also  occur  in  the  endometrium  of  a  fibroid 
uterus.  This  occurrence  is  by  no  means  an  unusual  one. 
We  cannot  yet  say  positively  that  the  fibroid  favors  the 
development  of  cancer,  but  it  seems  probable  that  the 
diseased  endometrium  that  accompanies  fibroids  furnishes 
a  place  of  diminished  resistance  for  the  development  of 
malignant  disease. 

Martin  has  made  an  interesting  analysis  of  205  cases 
of  fibroid  tumor  of  the  uterus  that  had  been  submitted  to 
operation.  From  this  analysis  we  may  form  some  esti- 
mation of  the  frequency  of  the  various  forms  of  de- 
generation that  have  been  described. 

Fatty  degeneration  existed  in  7  cases.  Calcification  was 
present  in  3  cases.  In  10  cases  there  was  suppuration, 
and  this  process  was  found  in  the  submucous,  interstitial, 
and  subperitoneal  tumors.  In  11  cases  there  was  exten- 
sive edema  of  the  fibroid.  In  8  cases  the  tumors  had 
become  cystic. 

The  telangiectatic  change  was  found  to  a  marked  de- 
gree in  3  cases. 


FIBROID  TUMORS  OF  THE  UTERUS.  237 

Sarcomatous  degeneration  had  occurred  in  6  cases. 

In  7  cases  the  fibroid  was  complicated  with  cancer  of 
the  fundus  uteri,  and  in  2  cases  with  cancer  of  the  neck 
of  the  womb. 

The  fatty  and  calcareous  changes  are  not  to  be  con- 
sidered dangerous  forms  of  degeneration. 

The  other  changes,  however,  are  often  attended  with 
great  danger  to  life.  The  dangers  of  suppuration  and  of 
sarcomatous  degeneration  are  obvious.  The  edematous 
fibroid  is  often  of  rapid  and  unlimited  growth,  and  is  usu- 
ally accompanied  by  profuse  hemorrhages  from  the  uterus. 
The  cystic  fibroid  may  grow  as  rapidly  and  as  large  as  an 
ovarian  cyst.  The  telangiectatic  tumors  grow  to  large 
size  and  are  attended  by  the  dangers  of  thrombosis  and 
embolism. 

Cancer  of  the  fundus  with  fibroid  tumor  may  only  be 
a  coincidence,  and  we  will  not  assume  that  predisposition 
to  cancer  is  caused  by  the  fibroid. 

The  statistics  that  have  been  given,  however,  show 
that  in  at  least  38  cases  out  of  205,  or  in  about  18  per 
cent,  of  the  cases,  changes  took  place  in  the  fibroid  that 
seriously  endangered  the  life  of  the  woman. 

Sterility,  abortion,  and  difficult  or  impossible  labor  are 
caused  by  uterine  fibroids.  Conception  is  impeded  on 
account  of  the  displaced,  distorted  uterus  and  the  hem- 
orrhage and  discharge.  Abortion  is  likely  to  occur,  on 
account  of  the  endometritis  and  the  unequal  expansibility 
and  the  irritability  of  the  uterus. 

Labor  is  sometimes  rendered  impossible  by  the  pres- 
ence of  a  uterine  fibroid  that  obstructs  the  pelvis,  and 
Cesarean  section  has  been  performed  for  this  cause. 

The  cause  of  fibroid  tumor  of  the  uterus  is  unknown. 
Some  authorities  consider  the  condition,  or  at  least  the 
predisposition  to  the  condition,  to  be  congenital.  Ute- 
rine fibroids  have  been  observed  in  girls  near  the  age  of 
puberty,  and  hysterectomy  for  fibroid  has  been  performed 
at  the  age  of  eighteen. 

Usually  the  disease  begins  to  cause  symptoms,  and  first 


238     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

comes  under  the  observation  of  the  physician,  after  the 
thirtieth  year.  It  is  very  probable  that  small  interstitial 
or  subperitoneal  fibroids  exist  in  many  women  before  this 
period,  but,  on  account  of  the  small  size  and  the  position 
of  the  growths,  they  produce  no  marked  symptoms,  and 
if  the  woman  bears  children,  the  tumors  are  very  likely 
absorbed  during  the  process  of  uterine  involution. 

Fibroid  tumors  occur  in  both  the  white  and  the  black 
races — with  somewhat  greater  frequency  in  the  latter 
than  in  the  former.  Tait  says  that  fibroid  tumors  of  the 
uterus  are  unknown  among  the  black  women  of  Africa. 
The  disease  is  certainly  very  common  among  their  de- 
scendants in  this  country. 

The  frequency  of  uterine  fibroids  is  difficult  to  deter- 
mine, for  there  are  many  cases  in  which  the  disease  is 
unrecognized  on  account  of  the  small  size  of  the  tumor 
and  the  absence  of  symptoms.  It  is,  however,  one  of 
the  commonest  diseases  with  which  women  suffer.  In 
504  celiotomies  performed  for  diseases  of  women  during 
the  past  three  years  at  the  University  and  Gynecean  Hos- 
pitals, uterine  fibroids  were  found  in  85,  or  in  about  17 
per  cent,  of  the  cases. 

Fibroid  tumors  are  found  both  in  multiparous  and  in 
nuUiparous  women — much  more  frequently  in  the  latter 
than  in  the  former.  Single  women  and  sterile  married 
women  are  especially  predisposed  to  this  disease.  There 
are  two  probable  causes  for  this  difference.  The  unceas- 
ing congestions  of  menstruation  favor  the  development 
of  the  neoplasm;  and,  when  once  started,  its  further 
growth  is  not  checked  by  the  retrograde  changes  that 
accompany  involution  of  the  uterus,  and  that  sometimes 
cause  the  disappearance  of  even  large  fibroids. 

Fibroid  tumors  are  essentially  growths  of  the  men- 
strual life  of  the  woman.  They  usually  first  appear  after 
the  thirtieth  year,  and  they  continue  to  grow  until  the 
menopause.  The  size  of  the  tumor  and  the  severity  of 
all  the  symptoms  progressively  increase  during  the  active 
sexual  period  of   life.     It  is  very  unusual  for  favorable 


FIBROID  TUMORS  OF  THE  UTERUS.  239 

retrograde  changes  or  permanent  amelioration  of  symp- 
toms to  occur  during  this  period.  In  a  woman  with 
fibroid  tumor  of  the  uterus  the  menopause  is  delayed  for 
five  to  fifteen  years  beyond  the  normal  time.  This  is  an 
important  fact  to  be  remembered  in  connection  with  the 
prognosis  and  the  treatment  of  any  case. 

At  the  menopause,  in  the  majority  of  cases,  the  growth 
of  the  tumor  is  arrested,  and  the  retrograde  changes  that 
affect  the  genital  apparatus  involve  also  the  fibroid  tumor, 
and  atrophy  of  the  neoplasm,  with  marked  diminution  in 
size,  and  in  some  cases  its  complete  disappearance,  may 
take  place.  The  tumor  becomes  quiescent,  and  the 
woman  may  finish  her  life  in  comparative  comfort.  This, 
however,  is  by  no  means  always  the  case.  The  fibroid 
sometimes  continues  to  grow  after  the  menopause,  and 
the  suffering  is  sometimes  so  unbearable  that  the  woman 
is  finally  driven  to  operation. 

In  some  cases  the  tumor  has  developed  entirely  after 
the  menopause  has  been  reached. 

At  each  menstrual  period  there  is  usually  a  decided  in- 
crease in  the  size  of  the  tumor  and  in  the  severity  of  the 
symptoms.  And  at  these  periods,  in  the  case  of  a  sub- 
mucous or  an  interstitial  fibroid,  the  cervical  canal  be- 
comes more  patulous. 

Symptoms. — The  chief  symptom  of  fibroid  tumor  of 
the  uterus  is  hemorrhage.  This  symptom  is  present  in 
the  great  majority  of  fibroids  of  all  kinds.  It  is  not, 
however,  universally  present.  I  have  removed  tumors 
the  size  of  the  adult  head,  composed  of  interstitial  and 
subperitoneal  fibroids,  from  women  who  had  never  suf- 
fered with  even  slight  menorrhagia.  The  hemorrhage 
appears  in  the  form  of  menorrhagia  or  metrorrhagia.  It 
may  be  an  increase  in  the  regular  menstrual  bleeding. 
It  may  appear  as  a  periodical  bleeding  occurring  every 
two  weeks — a  phenomenon  that  occurs  in  other  diseases 
of  the  uterus  and  the  endometrium.  It  may  appear  as  a 
show  of  blood  or  a  slight  hemorrhage,  after  unwonted 
effort,  between  the  regular  menstrual  periods.     This  may 


240     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

occur  after  straining  at  stool,  coitus,  or  even  emotional 
disturbance.  And,  finally,  it  may  appear  as  a  continuous 
bleeding  from  the  uterus. 

The  cause  of  these  hemorrhages  is  to  be  found  in  the 
increased  area  of  the  endometrium  accompanying  the 
uterine  enlargement,  and  in  the  diseased  condition  of  the 
endometrium. 

The  hemorrhage  is  not  usually  alarming  in  amount, 
and  it  may  be  somewhat  controlled  by  rest  in  bed  and  the 
administration  of  ergot  or  other  drugs.  In  some  cases, 
however,  it  produces  the  most  profound  anemia,  and  in 
others,  especially  in  the  uterine  polyp,  the  woman  may 
literally  bleed  to  death. 

The  symptom  of  hemorrhage  is  independent  of  the  size 
of  the  tumor,  but  depends  upon  the  position  of  the 
fibroid.  As  a  rule,  the  hemorrhage  is  most  severe  with 
the  uterine  polyp,  less  severe  with  the  submucous  and 
the  interstitial  tumors,  and  least  with  the  subperitoneal 
variety.  In  some  cases,  when  the  mucous  membrane 
overlying  a  submucous  tumor  ruptures,  the  hemorrhage 
may  come  directly  from  venous  sinuses  in  the  capsule. 

The  hemorrhage  also  depends  upon  the  variety  of  the 
growth.  The  edematous  fibroid  and  the  soft  myoma  ap- 
pear always  to  be  accompanied  by  profuse  bleeding.  In 
some  cases  the  hemorrhage  may  occur  periodically  or 
continuously  in  old  women  who  have  passed  the  meno- 
pause, and  in  whom  there  had  been  no  bleeding  for 
several  years.  This  has  been  observed  in  the  small  sub- 
mucous fibroids  which,  after  a  period  of  quiescence,  have 
gradually  become  polypoid,  or  which  have  undergone 
suppuration  and  disintegration.  The  hemorrhage,  the 
offensive  odor  of  the  discharge,  and  the  age  and  the 
history  of  the  patient  are  very  likely  to  lead  to  the  diag- 
nosis of  cancer. 

The  blood  that  escapes  from  the  fibroid  uterus  may  be 
fluid  or  clotted,  or  it  may  be  partly  decomposed  from  the 
retention  of  clots. 

A  profuse   secretion  from   the  utricular  glands   often 


FIBROID  TUMORS  OF  THE  UTERUS.  241 

occurs  between  the  uterine  hemorrhages.  This  secretion 
is  usually  thin  and  watery  in  character,  and  may  be  so 
profuse  as  to  require  the  continuous  wearing  of  a  napkin. 
In  some  unusual  cases  there  is  no  marked  hemorrhage, 
but  a  continuous  abundant  watery  discharge. 

Pain  is  a  more  or  less  constant  accompaniment  of 
fibroid  tumors.  It  varies  a  great  deal  in  character  and 
position.  It  is  often  referred  to  the  sacrum  and  to  the 
top  of  the  head  or  the  occiput.  .  Pain  of  this  character 
is  due  to  the  accompanying  metritis  and  endometritis. 
That  it  is  uterine  in  origin  is  shown  by  the  fact  of  its 
complete  and  permanent  disappearance  from  the  day  that 
hysterectomy  is  performed. 

The  pain  is  always  increased  at  the  menstrual  periods, 
and  may  at  first  be  present  only  at  these  times.  It  after- 
wards becomes  continuous. 

In  the  case  of  a  subipucous  or  a  polypoid  fibroid  there 
may  be  present  the  pain  of  uterine  contractions,  referred 
to  the  center  of  the  lower  abdomen,  and  resembling 
labor-pains. 

The  pain  from  pressure  is  sometimes  intense.  It  occurs 
in  large  tumors  and  in  those  of  pelvic  growth,  like  the 
intra-ligamentous  fibroids.  Sciatic  or  crural  neuralgia 
may  be  thus  developed. 

In  all  these  cases  there  is  a  feeling  of  weight  and  drag- 
ging in  the  pelvis  which  is  most  marked  in  the  erect  po- 
sition, and  which  is  caused  by  the  weight  of  the  tumor 
and  of  the  enlarged  uterus. 

The  symptoms  of  pressure  are  very  marked  in  the  case 
of  intra-ligamentous  tumors.  The  capacity  of  the  bladder 
may  be  so  diminished  that  there  may  be  continuous  in- 
continence of  urine;  or  the  bladder  and  the  urethra  may 
be  so  distorted,  from  traction  and  pressure,  that  urine  is 
voided  with  great  difficulty,  and  it  is  sometimes  impos- 
sible to  introduce  the  catheter.  I  have  seen  a  woman 
with  a  fibroid  the  size  of  the  adult  head  who  could  uri- 
nate only  when  upon  her  hands  and  knees. 

Pressure  upon  the  pelvic  nerves  may,  as  has  already 

]6 


242      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

been  mentioned,  produce  great  pain,  and  in  some  cases 
paralysis.  Women  are  sometimes  affected  with  sudden 
complete  paralysis  of  one  or  both  legs  from  the  pressure 
of  a  fibroid.  I  have  performed  hysterectomy  upon  a 
woman  who  had  on  several  occasions  fallen  helpless  in 
the  street  from  paralysis  of  the  left  leg  caused  by  the  pres- 
sure of  a  small  intra-ligamentous  fibroid  tumor.  All  the 
pressure-symptoms  are  exaggerated  at  the  menstrual 
period,  on  account  of  the  swelling  of  the  tumor  that 
occurs  at  this  time. 

Pressure  upon  the  rectum  is  often  very  marked,  and 
may  cause  constipation  and  hemorrhoids.  Pressure  upon 
the  ureters  causes  dilatation,  hydronephrosis,  and  ure- 
mia. This  is  a  not  infrequent  cause  of  death,  both  in 
the  untreated  case  and  after  operation  for  the  relief  of 
fibroids. 

The  effect  of  fibroid  tumors  of  large  size  upon  the  heart 
and  blood-vessels  has  been  remarked  by  several  writers. 
Fatty  degeneration  and  brown  atrophy  have  been  found 
associated  with  uterine  fibroids  in  a  number  of  instances. 
This  is  undoubtedly  the  explanation  of  some  cases  of 
death  after  operation. 

Martin  has  called  attention  to  the  disposition  to  throm- 
bosis and  embolism  which  seems  to  be  especially  marked 
in  the  telangiectatic  form  of  tumor.  This  also  explains 
some  of  the  cases  of  sudden  death  that  occur  after  opera- 
tion. Operators  have  observed  cases  of  sudden  death, 
probably  from  embolism,  occurring  sometimes  several 
weeks  after  hysterectomy  for  fibroid  tumor. 

The  diagfnosis  of  uterine  fibroids  is  made  from  a  study 
of  the  symptoms  already  described  and  from  the  physical 
examination. 

If  the  tumor  is  large  enough  to  be  palpated  through 
the  abdominal  wall,  the  hard  consistency  and  the  irregu- 
lar bossed  outline  of  the  multinodular  form  of  fibroid  may 
be  detected. 

By  bimanual  examination  we  determine  the  general 
enlargement,  and  perhaps  the  irregular  outline,   of   the 


FIBROID  TUMORS  OF  THE  UTERUS.  243 

uterus.  Sometimes,  when  the  fibroid  is  small  and  inter- 
stitial, a  slight  elevation,  or  perhaps  merely  a  local  in- 
duration, may  be  felt.  By  grasping  the  cervix  with  a 
tenaculum  and  drawing  it  down  while  the  palpating  finger 
is  in  the  rectum  the  whole  of  the  posterior  face  of  the 
uterus  may  be  explored  and  small  fibroid  nodules  dis- 
covered. 

The  tumors  are  found  to  be  continuous  with  the  uterus 
and  movable  with  it.  If  the  tumor  is  sufficiently  large  to 
be  grasped  by  an  assistant,  who  draws  it  up  or  to  either  side, 
it  will  be  found  that  the  motion  is  communicated  to  the 
vaginal  cervix.  The  cervix  is  often  very  hard,  and  may 
have  been  dragged  upward  to  such  an  extent  that  it  can- 
not be  reached  by  the  vaginal  finger;  or  it  may  project 
from  the  rounded  surface  of  the  tumor  like  the  nipple  on 
the  breast. 

The  hard,  non-fluctuating  character  of  the  tumor  may 
usually  be  determined  by  bimanual  examination.  A  sen- 
sation resembling  that  of  fluctuation  may  be  elicited  in 
the  edematous  fibroid,  and  true  fluctuation  is,  of  course, 
present  in  the  cystic  variety. 

The  uterine  sound  shows  the  increased  length  and  the 
irregularity  of  the  uterine  cavity.  The  sound  is  not  often 
necessary  for  diagnosis.  It  is  useful,  however,  in  the  case 
of  small  interstitial  fibroids.  It  will  be  remembered  that 
uterine  enlargement  is  one  of  the  most  usual  symptoms 
of  fibroid  tumor. 

The  presence  in  the  wall  of  the  uterus  of  a  hard  nodule 
or  of  an  area  of  induration,  with  a  decided  increase  in  the 
length  of  the  uterine  cavity  (three  to  four  inches),  is  strong 
evidence  of  fibroid  tumor. 

Those  fibroid  tumors  which  cause  symmetrical  uterine 
hypertrophy  without  any  irregularity  of  surface  are  some- 
times difficult  of  diagnosis.  They  have  been  mistaken 
for  the  pregnant  uterus.  The  reverse  mistake  has  also 
very  frequently  been  made,  and  the  woman  has  been  sub- 
jected to  celiotomy  for  fibroid  tumor  when  a  normal  preg- 
nancy alone  was  present.     The  differential  diagnosis  be- 


244      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

tween  fibroid  and  pregnancy  is  nsually  not  difficult.  In 
making  such  a  differential  diagnosis  it  must  be  remem- 
bered that  in  some  cases  of  pregnancy  the  menstrual  pe- 
riods continue  during  the  early  months  or  throughout  the 
course  of  pregnancy,  and  that  irregular  bleeding  may 
occur  during  pregnane)-;  also,  on  the  other  hand,  that 
the  s}-mptonis  of  menorrhagia  and  metrorrhagia  may  be 
absent  in  the  case  of  fibroid  tumors.  IMammary  changes, 
nausea,  and  pigmentation  of  the  skin  may  occur  with 
fibroid  tumors  as  with  other  diseases  of  the  uterus  or 
the  ovaries,  and  resemble  the  similar  phenomena  of  preg- 
nancy. The  bluish  discoloration  of  the  ostium  vaginae, 
the  soft  cervix,  the  pulsation  of  the  vaginal  vessels,  the 
movements  of  the  child,  and  the  fetal  heart-sounds  are 
absent  in  fibroid  tumors.  The  recent  history  of  the 
tumor  and  its  typical  increase  in  size  are  observed  in 
pregnancy. 

In  the  event  of  doubt  the  case  should  be  watched  for 
a  few  months  until  the  diagnosis  becomes  clear.  Fibroid 
tumors  are  of  slow  growth,  and  such  delay  is  usually  not 
dangerous. 

If  the  fibroid  tumor  is  complicated  with  pregnancy, 
the  diagnosis  becomes  more  difficult.  This  complica- 
tion is  not  an  unusual  one,  and  should  always  be  borne 
in   mind. 

The  differential  diagnosis  between  uterine  fibroid  and 
ovarian  cyst  is  easy  except  in  the  case  of  the  fibro-cystic 
tumor.  Such  tumors  have  very  often  been  mistaken  for 
ovarian  cysts.  The  mistake  is  not  at  all  serious,  as  celi- 
otomy is  indicated  in  either  case.  The  operator,  how- 
ever, should  always  determine  the  nature  of  the  tumor 
before  proceeding  with  the  operation  after  the  abdomen 
has  been  opened,  as  puncture  of  a  fibro-cystic  tumor  may 
be  attended  by  alarming  hemorrhage. 

A  small  fibroid  in  the  posterior  wall  of  the  uterus  has 
often  been  mistaken  for  retroflexion,  and  the  woman  has 
been  treated  with  a  pessary.  This  mistake  may  be 
avoided  by  feeling,  with  the  abdominal  hand,  the  fundus 


FIBROID  TUMORS  OF  THE  UTERUS.  245 

uteri  in  its  normal  forward  position,  or  by  determining 
the  true  direction  of  the  uterus  with  the  uterine  sound. 

The  prognosis  of  uterine  fibroids  may  be  determined 
from  a  consideration  of  the  natural  history,  the  degenera- 
tions, and  the  complications  of  these  neoplasms,  which 
have  already  been  described. 

Fibroid  tumors  are  benign  growths,  in  contradistinction 
to  cancer  and  sarcoma.  They  do  not  infiltrate  contigu- 
ous structures  or  invade  the  general  system;  but  they  are 
not  benign  in  the  sense  that  they  are  not  dangerous  to 
life. 

As  has  been  said,  the  disease  may  terminate  as  a  ute- 
rine polyp,  which  may  be  discharged  from  the  body.  But 
during  this  process  the  woman  may  die  from  hemor- 
rhage or  from  septic  absorption  from  the  sloughing,  dis- 
integrating tumor. 

Some  unusual  fibroids  give  no  trouble  whatever,  never 
attain  a  large  size,  and  are  discovered  only  accidentally 
during  the  life  of  the  woman  or  at  the  autopsy. 

In  very  exceptional  cases — so  rare  that  they  are  to  be 
looked  upon  as  medical  curiosities — the  fibroid  disappears 
spontaneously  even  after  it  has  reached  a  large  size. 
This  has  occurred  as  the  result  of  an  accident,  explora- 
tory celiotomy,  and  pregnancy. 

We  have  no  right  in  any  case,  however,  to  look  for 
such  favorable  termination. 

The  accidents  that  may  happen  to  the  tumor  itself,  and 
which  imperil  the  life  of  the  woman,  are  various  and 
occur  frequently.  The  dangerous  forms  of  degeneration 
— the  edematous,  the  cystic,  the  telangiectatic,  and  the 
sarcomatous — occur  with  sufficient  frequency  always  to 
be  dreaded;  and,  even  though  these  dangers  be  avoided, 
the  anemia  from  the  continual  hemorrhage  exposes  the 
woman  to  fatal  results  from  the  diseases  and  accidents  of 
daily  life.  The  most  favorable  course  that  we  have  a 
right  to  expect,  in  any  case  of  fibroid  tumor  of  the  uterus 
that  is  not  discharged  as  a  uterine  polyp,  is  that  it  will 
grow  slowly,   that  it  will  produce  symptoms  not  unen- 


246     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

durable,  and  that  at  the  menopause  it  will  cease  to  grow 
and  will  atrophy  or  disappear. 

This  comparatively  favorable  course  condemns  the 
woman  to  a  life  of  invalidism,  more  or  less  marked,  dur- 
ing the  years  that  should  be  the  most  useful  and  active 
of  her  existence  The  menopause  may  be  delayed  for 
five,  ten,  or  fifteen  3^ears,  or  it  may  be  indefinitely  post- 
poned ;  and  even  after  the  menopause  has  occurred,  in  a 
certain  number  of  cases  the  fibroid,  contrary  to  the  usual 
rule,  continues  to  grow,  and  may  ultimately  cause  death. 

Treatment  of  Fibroid  Tumors  of  the  Uterus. — 
Operative  treatment  is  usually  demanded  in  the  case  of 
fibroid  tumors.  A  few  years  ago  the  treatment  usually 
advised  was  palliative  and  expectant.  The  imperfect 
technique  rendered  operations  for  this  disease  so  fatal 
that  it  was  considered  safest  for  the  woman  to  allow  the 
tumor  to  pursue  its  natural  course,  hoping  that,  if  small 
and  single,  it  would  be  discharged  as  a  polyp,  or  that  it 
would  grow  slowly  and  would  atrophy  at  the  menopause, 
the  physician  meanwhile  relieving  as  much  as  possible, 
by  palliative  treatment,  the  symptoms  that  presented  be- 
fore this  favorable  termination. 

Many  women,  following  this  advice,  have  suffered 
through  the  years  of  active  life,  and  have  finally  found 
relief  and  cure  when  the  menopause  was  reached;  others 
have  started  upon  this  dreary  course,  and  have  died  from 
some  of  the  accidents  incident  to  these  tumors;  still 
others  have  passed  through  these  years  of  suffering,  and 
then  have  found  the  hoped-for  goal  vanished,  the  meno- 
pause indefinitely  postponed,  or  the  tumor  continuing  to 
grow  after  this  period  had  been  reached. 

Many  of  these  women  are  driven  to  the  operating-table 
to-day,  after  lives  that  have  been  wasted  by  this  expectant 
plan  of  treatment. 

The  great  majority  of  fibroid  tumors  of  the  uterus 
demand  immediate  operation.  The  operative  technique 
has  been  so  perfected  that  the  mortality  after  operation  is 
very  small.     The  danger  of  operation  is  much  less  than 


FIBROID  TUMORS  OF  THE  UTERUS.  247 

the  dangers  to  which  the  woman  is  exposed  from  the 
various  accidents  that  are  liable  in  this  disease. 

There  are  some  cases,  however,  in  which  immediate 
operation  is  not  demanded.  In  a  young  woman  with  a 
fibroid  tumor  of  small  size  that  is  not  causing  serious 
symptoms  operation  may  be  deferred  and  the  case  may 
be  watched.  This  plan  is  especially  desirable  if  the 
woman  is  anxious  to  have  children.  She  should  be  told, 
however,  that  conception  is  less  likely  to  occur  than  in 
the  well  woman,  that  she  is  liable  to  abort,  and  that  the 
tumor  will  grow  more  rapidly  during  her  pregnancy. 
On  the  other  hand,  there  is  the  possibility  of  its  disap- 
pearance after  labor. 

If  the  tumor,  even  though  small,  is  intra-ligamentous 
and  of  pelvic  growth,  the  expectant  plan  of  treatment  is 
not  justifiable.  Dangerous  pressure-symptoms  are  toa 
imminent,  and  if  pregnancy  occurs  labor  will  be  ob- 
structed. If  the  woman  has  reached  the  menopause,  if 
menstruation  has  ceased, .  and  the  tumor  is  causing  no 
serious  symptoms  from  its  size  and  position,  the  case  may 
be  watched  with  the  hope  that  the  disease  will  shortly 
become  quiescent.  Such  cases  are  exceptional.  Usually 
the  tumor  produces  symptoms  that  render  the  woman 
more  or  less  of  an  invalid,  and  she  should  not  be  con- 
demned to  this  suffering  and  to  the  dangers  of  waiting. 
In  these  cases  we  must  not  rely  altogether  upon  the  state- 
ment of  the  woman  in  regard  to  the  suffering  caused  by 
the  tumor.  A  woman,  dreading  operation,  will  often 
underrate  her  suffering,  or  she  will  consider  as  normal 
the  disturbances  to  which  she  has,  through  a  long  period 
of  years,  gradually  become  accustomed. 

No  drug  has  been  discovered  that  has  any  influence 
upon  the  growth  of  the  fibroid  tumor. 

The  most  serious  symptom,  hemorrhage,  may  be  alle- 
viated in  a  variety  of  ways.  Rest  in  the  recumbent  pos- 
ture, to  relieve  congestion,  is  most  important.  Such  rest 
is  especially  demanded  at  the  menstrual  period.  Pres- 
sure-symptoms and  pain  are    likewise  relieved  by  rest. 


248      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Careful  attention  to  the  regularity  of  the  bowels  is  desir- 
able. The  administration  of  saline  purgatives  to  the 
extent  of  mild  purgation  depletes  the  pelvic  circulation, 
and  is  especially  useful  immediately  before  a  menstrual 
period.  Coitus  should  be  avoided  immediately  before 
and  during  the  menstrual  period. 

Ergot,  gallic  acid,  hydrastis,  bromide  of  potash,  and 
erigeron  are  useful  to  control  the  bleeding.  They  should 
be  administered  in  frequently  repeated  doses  for  a  long 
period. 

Thorough  curetting  of  the  cavity  of  the  uterus  is  the 
most  certain  method  of  controlling  the  hemorrhage.  By 
this  procedure  the  diseased  endometrium  is  removed,  and 
the  bleeding  is  usually  very  decidedly  diminished  for  sev- 
eral months  afterwards. 

The  treatment  by  electricity,  once  popular  with  some 
physicians,  has  not  stood  tiie  test  of  time  and  experience. 
It  does  not  stop  the  growth  of  the  tumor.  It  has  caused 
many  deaths.  It  may  produce  peritoneal  adhesions, 
which  render  subsequent  operation  most  difficult. 

Ligation  of  the  uterine  arteries  for  the  cure  of  fibroid 
tumors  of  the  uterus  has  been  practised  by  a  few  operators 
during  the  past  five  years.  The  object  of  this  operation 
is  to  arrest  the  growth  of  the  tumor  or  to  produce  atrophy 
by  diminishing  its  blood-supply.  The  few  reported  cases 
seem  to  show  that  the  operation  may  sometimes  do  good. 
The  operation  has  certainly  not  become  popular,  and  it 
must  be  considered  to  be  still  on  trial.  It  is  not  applic- 
able to  large  tumors  or  to  tumors  that  are  producing  seri- 
ous pressure-symptoms.  The  object  sought  may  be  de- 
feated by  the  establishment  of  the  collateral  circulation. 
In  many  cases  the  distortion  of  anatomical  relationships 
that  occurs  with  uterine  fibroids  renders  the  operation, 
as  usually  performed,  impossible,  because  one  or  both 
uterine  arteries  may  be  far  removed  from  the  normal 
position. 

The  operation  is  performed  through  the  vagina.  Doug- 
las's pouch  is  opened,  lateral  incisions  are  made  in  the 


FIBROID  TUMORS  OF  THE  UTERUS.  249 

vaginal  vault  across  the  bases  of  the  broad  ligaments, 
and  the  arteries  are  secured  by  ligatures. 

The  operations  usually  performed  for  the  cure  of  ute- 
rine fibroids  are  salpingo-oophorectomy,  or  removal  of 
the  Fallopian  tubes  and  the  ovaries;  and  hysterectomy, 
or  removal  of  the  uterus. 

Salpingo-oophorectomy  has  been  practised  for  a  number 
of  years,  and  a  large  number  of  fibroid  tumors  have  been 
cured  by  it.  Before  the  present  perfected  technique  of 
hysterectomy  had  been  developed  salpingo-oophorectomy 
was  much  the  safer  operation,  and  was  always  practised 
whenever  possible. 

The  object  of  the  operation  is  to  cause  arrest  of  growth 
and  atrophy  of  the  tumor  by  stopping  menstruation  and 
producing  a  premature  menopause. 

According  to  the  statistics  of  Tait,  the  operation  results 
in  cure  of  the  fibroid  in  95  per  cent,  of  the  cases. 

In  some  cases  the  bleeding  stops  immediately  and  never 
recurs;  in  other  cases  the  bleeding  continues,  in  steadily 
diminishing  amount,  for  several  weeks  or  a  few  months 
after  the  operation;  and  finally,  in  a  small  proportion  of 
the  cases,  the  bleeding  is  not  arrested  at  all. 

The  atrophy  of  the  tumor  after  this  operation  is  also 
variable.  Sometimes  the  atrophy  begins  immediately, 
and  in  a  few  weeks  after  the  operation  has  proceeded  to 
a  very  marked  degree,  the  tumor  disappearing  or  being  so 
small  as  to  give  no  trouble;  in  other  cases  the  atrophy 
is  much  slower;  sometimes  there  is  no  arrest  of  growth 
whatever. 

The  operation  seems  to  produce  most  benefit  in  cases 
of  the  hard  fibroid.  The  edematous  fibroid  is  often  un- 
affected by  it;  and  it  is  not  applicable  in  the  case  of  fibro- 
cystic tumors,  which  continue  in  unabated  growth. 

In  performing  the  operation  it  is  important  that  every 
portion  of  ovarian  tissue  should  be  removed,  and  that  the 
Fallopian  tube  should  be  amputated  as  closely  as  possible 
to  the  uterine  cornu.  Many  cases  of  failure  of  this  ope- 
ration are  due  to  neglect  of  these  precautions. 


250     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

A  very  small  portion  of  ovarian  tissue  may  be  sufficient 
to  continue  menstruation. 

A  good  many  women  who  had  derived  no  benefit  from 
the  first  operation  have  been  subjected  to  a  second  opera- 
tion, a  small  remaining  portion  of  the  ovary  being  re- 
moved or  the  stump  of  the  Fallopian  tube  being  excised, 
complete  cure  resulting. 

The  nature  of  the  influence  of  the  Fallopian  tube  in 
this  matter  is  not  understood.  Tait  lays  especial  stress 
upon  the  necessity  of  its  complete  removal. 

The  importance  of  the  removal  of  the  tubes  may  be 
realized  from  Tait's  statement  that  "  removal  of  the  ova- 
ries alone  is  followed  by  immediate  and  complete  arrest 
of  menstruation  in  about  50  per  cent,  of  the  cases.  Re- 
moval of  both  tubes,  with  or  without  the  ovaries,  is  fol- 
lowed by  the  same  arrest  in  about  90  per  cent,  of  the 
cases."  From  this  statement  it  appears  that  if  one  wishes 
to  stop  menstruation,  removal  of  the  tubes  is  of  even 
more  importance  than  removal  of  the  ovaries. 

The  operation  of  salpingo-oophorectomy  is  not  advis- 
able in  some  cases,  and  in  some  others  it  is  impossible  to 
perform  it. 

As  has  already  been  said,  the  operation  is  likely  to  fail 
in  the  soft  edematous  fibroids.  It  should  not  be  advised 
in  the  fibro-cystic  tumors.  It  is  not  advisable  in  the  case 
of  large  fibroid  tumors  of  abdominal  growth,  because, 
even  though  atrophy  occur,  it  will  be  slow,  and  the  symp- 
toms referable  to  the  large  hard  tumor  in  the  abdomen 
will  be  but  slowly  relieved. 

The  operation  is  not  applicable  to  the  intra-ligamentous 
fibroid  of  pelvic  growth,  producing  urgent  pressure- 
symptoms  that  demand  certain  and  immediate  relief.  In 
the  case  of  profuse  exhausting  hemorrhage,  when  the 
anemia  is  so  great  that  immediate  and  certain  arrest  of 
bleeding  is  required,  salpingo-oophorectomy  should  not 
be  practised. 

If  the  woman  has  reached  the  menopause,  and,  not- 
withstanding the   cessation  of  menstruation,  the  tumor 


FIBROID  TUMORS  OF  THE  UTERUS.  251 

continues   to   grow,    salpingo-oophorectomy  will    do   no 

good. 

In  some  cases  the  tubes  and  ovaries  cannot  be  removed. 
They  often  occupy  a  position  behind  or  under  the  tumor, 
so  that  they  cannot  be  removed  without  first  taking  the 
tumor  away.  The  tube  and  ovary  may  be  so  distorted 
that  only  partial  excision  is  possible,  and  this  will  result 
in  no  benefit;  or  the  tube  and  ovary  may  be  spread  out 
upon  the  face  of  the  tumor,  incorporated  with  its  capsule, 
so  that  removal  is  impossible,  and  any  attempt  at  removal 
may  result  in  rupture  or  penetration  of  large  venous 
sinuses — a  most  dangerous  accident. 

The  operator  should  therefore  never  undertake  the 
operation  of  salpingo-oophorectomy  for  uterine  fibroid 
unless  he  is  prepared  to  perform  hysterectomy  if  this 
operation  is  found  necessary. 

Hysterectomy  is  deservedly  the  favorite  operation  for 
uterine  fibroids  at  the  present  day. 

The  danger  of  the  operation  is  small,  being  but  little, 
if  any,  greater  than  that  attending  salpingo-oophorec- 
tomy for  fibroids,  if  we  compare  only  those  cases  in  which 
either  operation  may  be  performed. 

The  operation  is  applicable  to  every  kind  of  fibroid 
tumor.  The  relief  of  symptoms  is  immediate  and  cer- 
tain. 

The  reflex  symptoms,  such  as  backache  and  headache, 
which  are  directly  due  to  the  pathological  condition  of 
the  uterus,  often  disappear  immediately  and  permanently. 
This  cannot  be  said  of  salpingo-oophorectomy,  after 
which  operation  these  symptoms  often  continue  for  an 
indefinite  period. 

The  treatment  of  uterine  fibroids  has  followed  in  de- 
velopment the  growth  of  abdominal  and  pelvic  surgery. 
In  the  days  when  celiotomy  was  a  dangerous  operation 
the  palliative  treatment  was  advisable.  When  salpingo- 
oophorectomy  could  be  safely  performed  this  treatment 
was  practised;  and  now  that  hysterectomy  is  equally  safe, 
it  has  become  the  operation  of  election. 


252      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  details  of  the  operation  of  hysterectomy  for 
uterine  fibroids  will  be  considered  in  a  subsequent 
chapter. 

Myofnectoviy  {Abdo^nitial). — In  some  cases  of  uterine 
fibroid  it  is  possible  to  remove  the  tumor  without  taking 
away  the  uterus.  This  operation,  when  performed 
through  an  abdominal  incision,  is  called  abdominal 
myomectomy.  From  a  surgical  standpoint  it  is  the  ideal 
plan  of  treatment,  as  the  woman  is  cured  of  the  disease 
without  suffering  mutilation. 

Myomectomy  is  especially  adapted  to  the  treatment  of 
single  fibroid  tumors  which  may  be  excised  or  shelled 
out  of  the  body  of  the  uterus.  It  is  indicated  in  the 
case  of  young  women  who  are  anxious  for  children. 

The  field  of  myomectomy  is  at  present  a  limited  one. 
Single  subperitoneal  and  interstitial  fibroid  tumors  are 
rare.  Even  though  the  secondary  nodules  may  be  small 
at  the  time  of  operation,  they  will  grow  after  the  removal 
of  the  chief  mass.  Hysterectomy  has  been  required  at  a 
second  operation  in  a  woman  on  whom  myomectomy  had 
been  first  performed. 

The  operation  is  still  on  trial:  its  limitations  and 
remote  results  have  not  yet  been  determined.  It  should 
be  performed  only  by  the  experienced  abdominal  surgeon. 
Many  fatal  cases  of  post-operative  hemorrhage  and  of 
sepsis  have  occurred.  Though  successful  cases  have 
been  reported  by  men  of  unusual  skill  and  experience,  in 
which  large  numbers  of  uterine  fibroids  have  been  re- 
moved from  the  uterus  at  one  operation,  yet  these  cases 
must  be  looked  upon  as  rare  surgical  triumphs  which  it 
is  to  be  hoped  will  become  more  frequent  in  the  future. 

On  the  ground  of  safety,  hysterectomy  is  to  be  preferred 
to  myomectomy. 

The  details  of  the  operation  of  myomectomy  are 
described  in  a  subsequent  chapter. 

When  the  fibroid  tumor  is  complicated  by  pregnancy 
it  may  be  necessary  to  perform  Cesarean  section,  followed 
by  hysterectomy.     This  is  not  justifiable,  however,  un- 


FIBROID  TUMORS  OF  THE  UTERUS. 


253 


less  the  fibroid  is  so  situated  that  the  passage  of  the  child 
by  the  natural  way  is  impossible.  The  fibroid  usually 
increases  more  rapidly  in  size  during  pregnancy,  but  may 
diminish  a  good  deal  with  the  involution  of  the  uterus. 

Treatinent  of  the  Fibroid  Polyp. — When  the  fibroid 
tumor  is  polypoid,  and  projects  into  the  uterine  cavity,  or 
the  cervix,  or  beyond  the  external  os,  none  of  the  opera- 
tions that  have  just  been  described  are  required.  The 
tumor  should  then  be  attacked  by  way  of  the  vagina. 
If  the  fibroid  polyp  projects  from  the  external  os,  the 
pedicle  may  very  easily  be  divided  with  curved  scissors. 


Fig.  134. — Fibroid  polyp  producing  partial  inversion  of  the  uterus. 

If  the  tumor  is  still  within  the  cavity  of  the  uterus,  it 
will  be  necessary  to  dilate  the  cervix,  or  to  enlarge  the 
canal  by  lateral  incisions,  so  that  the  pedicle  may  be 
reached.  It  should  always  be  remembered  that  the  polyp 
may,  by  traction,  produce  partial  or  complete  inversion 
of  the  uterus  (Fig.  134),  and  in  dividing  the  pedicle, 
therefore,   the  operator  should   cut  close  to  the   tumor. 


254     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

leaving,  if  necessary,  a  portion  of  the  surface  of  the 
tumor.  In  case  the  polyp  is  so  large  that  the  vagina  is 
filled  to  such  an  extent  that  the  pedicle  is  not  accessible, 
it  is  advisable  to  remove  the  tumor  piecemeal,  grasping 
portions  with  a  tenaculum  and  cutting  away  with  scissors 
until  the  pedicle  is  reached.  The  fibroid  polyp  is  not 
vascular,  and  hemorrhage  is  not  alarming.  The  pedicle 
usually  contains  no  large  vessel.  It  retracts  after  the 
tumor  has  been  cut  away,  and  spontaneous  hemostasis  is 
secured.  It  was  formerly  the  custom  to  ligate  the  pedicle 
or  to  remove  the  polyp  with  the  ecraseur,  but  these 
methods  are  unnecessary.  If  any  hemorrhage  should 
follow  the  operation,  the  cavity  of  the  uterus  should  be 
packed  with  sterile  gauze. 


CHAPTER    XXI. 
HEMATOMETRA;    HYDROMETRA ;    PYOMETRA. 

If  there  exists  in  the  genital  tract  any  obstruction  that 
prevents  the  escape  of  menstrual  blood,  the  uterus 
will  become  distended  and  the  condition  of  hematomeira 
will  be  present.  If  the  retained  fluid  consists  chiefly  of 
the  mucous  secretion  of  the  utricular  glands,  the  condi- 
tion is  described  as  hydrometra;  or  if  suppuration  has 


Fig.  135. — Hematometra. 

taken  place,  so  that  the  uterus  becomes  distended  with 
pus,  the  condition  is  called  pyometra. 

The  uterine  walls  may  be  very  much  attenuated  by  the 
distention,  or  the  muscular  coat  may  hypertrophy  as  the 
accumulation  progresses. 

255 


256     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  cause  of  these  conditions  may  be  congenital  or 
acquired  atresia  of  any  part  of  the  genital  tract.  The 
symptoms  usually  appear  after  puberty.  The  menstrual 
period  is  accompanied  by  intense  bearing-down  pain  in 
the  region  of  the  uterus.  There  is  no  appearance  of  men- 
strual blood.  A  round  tumor  may  be  felt  in  the  hypo- 
gastrium.  Examination  will  reveal  the  obstruction  in 
the  cervical  canal.  Sometimes  the  chief  accumulation 
and  distention  occur  in  the  cervix;  in  other  cases  the 
body  of  the  uterus  is  chiejEiy  affected. 

Distention  of  the  Fallopian  tubes,  with  the  formation 
of  hematosalpinx,  hydrosalpinx,  or  pyosalpinx,  often  ac- 
companies old  cases  of  hematometra. 

The  treatment  consists  in  relieving  the  obstruction 
and  in  maintaining  the  patulous  condition  of  the  genital 
tract.  If  the  cervix  is  the  seat  of  the  obstruction,  it 
should  be  punctured  with  a  trocar  and  thoroughly  dilated. 
It  may  be  necessary  to  practise  repeated  dilatation  in 
order  to  keep  the  canal  open. 

The  accompanying  disease  of  the  Fallopian  tubes  may 
persist  after  drainage  of  the  uterus,  and  salpingo-oopho- 
rectomy  or  hysterectomy  may  be  ultimately  required. 


CHAPTER   XXII. 
TUBERCULOSIS  OF  THE  UTERUS. 

Tuberculosis  of  the  uterus  is  not  a  very  rare  disease. 
In  this  respect  it  differs  from  tuberculosis  of  the  cervix, 
which,  as  has  already  been  said,  is  a  most  unusual  site 
for  the  appearance  of  tuberculosis.  Even  in  advanced 
cases  of  tuberculosis  of  the  body  of  the  uterus  it  is  very 
rare  that  the  condition  extends  below  the  internal  os. 

Tuberculosis  of  the  uterus  is  often  found  post-mortem 
in  women  who  have  died  of  phthisis  or  other  form  of 
tubercular  disease.  It  has  also  been  recognized  during 
life,  and  operation  has  been  performed  for  its  relief 

Tuberculosis  of  the  uterus  seems  most  frequently  to  be 
secondary  to  a  tubercular  lesion  in  some  other  part  of  the 
body.  It  often  begins  in  the  Fallopian  tubes,  and  extends 
thence  to  the  endometrium;  or  it  may  be  primary  in  the 
endometrium,  caused  by  infection  through  the  genital 
tract. 

The  disease  first  attacks  the  endometrium,  and  in  the 
late  stages  extends  to  the  muscular  coat. 

Tuberculosis  of  the  endometrium  may  occur  in  three 
forms— miliary  tuberculosis,  chronic  diffuse  tuberculosis 
(caseous  endometritis),  and  chronic  fibroid  tuberculosis. 

Miliary  tuberculosis  of  the  uterus  may  be  part  of  a 
general  miliary  tuberculosis.  Typical  miliary  tubercles 
are  found  scattered  throughout  the  endometrium,  usually 
situated  immediately  beneath  the  epithelium  (Fig.  136). 

Chronic  diffuse  tuberculosis  is  the  most  frequent  form. 
The  uterine  cavity  is  filled  with  cheesy  material.  The 
mucous  membrane  is  the  seat  of  irregularly  shaped  ulcers 
and  tubercles  in  various  stages  of  development.  When 
the  disease  has  extended  to  the  muscular  coat  of  the 

17  257 


258     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

uterus,  the  whole  organ  becomes  considerably  enlarged. 
Degeneration  and  softening  of  the  uterine  wall  may  be 


.-      ■»      - 

i  c- 

■  :,,„«■- 

j 

t   f 

^^i'^ 

>i,  . 

..' 

\^  ■ 

■^•>'/^    ■     ■      , 

i 

f 

'***-,'v^  .-• 

,.\.J 

"'(i< 

t*- 

Fig.  136. — Miliary  tuberculosis  of  the  endometrium  and  glandular  endometritis 

(l3eyea). 

SO  extensive  as  to  cause  rupture.     The  internal  os  may 
become  closed,  and  a  pyometra  may  be  produced. 

Chronic  fibroid  tuberculosis  of  the  endometrium  seems 
to  be  the  rarest  form  of  the  disease.     A  microscopic  sec- 


FiG.  137. — Advanced  fibroid  tuberculosis  of  the  endometrium  (Beyea). 

tion  of  this  form  of  tuberculosis  is  shown  in  Fig.    137. 
The   endometrial  tissue  was   almost   entirely  destroyed, 


TUBERCULOSIS  OF  THE  UTERUS.  259 

and  was  replaced  by  a  mass  of  typical  miliary  tubercles. 
There  were  no  traces  of  glandular  tissue.  The  tubercles 
were  separated  from  each  other  by  a  very  extensive  small 
round-cell  infiltration  and  a  small  amount  of  remaining 
stroma  tissue.  To  the  naked  eye  the  endometrium  did 
not  appear  to  be  diseased. 

Tuberculosis  of  the  uterus  may  occur  at  any  period  of 
life.  It  is  most  often  found  between  the  twentieth  and 
fortieth  years. 

The  symptoms  of  tuberculosis  of  the  uterus  are  not 
at  all  characteristic.  In  the  early  stages  they  resemble 
those  of  non-tubercular  endometritis.  There  is  sometimes 
a  very  profuse  leucorrhea,  which  may  contain  the  charac- 
teristic cheesy  material.  The  body  of  the  uterus  may  be 
considerably  hypertrophied.  If  the  condition  follows 
tuberculosis  elsewhere,  or  if  any  form  of  genital  tuber- 
culosis exists  in  the  husband,  the  physician  would  be  led 
to  suspect  tuberculosis  of  the  uterus. 

The  diagntiosis  can  be  made  only  by  thorough  curet- 
ting of  the  uterine  cavity  and  the  microscopic  examina- 
tion of  the  tissue  removed.  The  tubercle  bacillus  has 
not  often  been  found,  but  the  other  microscopic  appear- 
ances are  frequently  characteristic.  In  the  case  from 
which  the  section  shown  in  Fig.  137  was  taken  the  diag- 
nosis of  tuberculosis  of  the  endometrium  was  made  by 
such  curetting  and  examination. 

The  treatment  of  tuberculosis  of  the  uterus  is  hyste- 
rectomy. The  operation  is  indicated  in  every  case  except 
those  in  which  there  is  present  in  some  other  part  of  the 
bodv  an  incurable  tubercular  lesion. 


CHAPTER    XXIII. 
INVERSION  OF  THE  UTERUS. 

In  inversion  of  the  uterus  this  organ  is  turned  partly 
or  completely  inside  out.  The  condition  usually  results 
from  childbirth  or  from  the  growth  of  an  interstitial  or 
polypoid  tumor. 

There  seem  to  be  two  factors  that  result  in  the  pro- 
duction of  inversion:  a  degeneration  or  atrophy  of  part 
of  the  uterine  wall,  and  traction,  as  from  the  drag  of  a 
uterine  polyp  or  of  the  umbilical  cord.  These  causes 
may  act  together  or  independently. 

If  a  portion  of  the  uterine  wall  has  lost  its  strength  or 
tonicity,  it  may  be  depressed  toward  the  uterine  cavity. 
The  depression  is  increased  by  the  traction  of  a  tumor  or 
of  the  umbilical  cord.  The  inversion  having  been  started 
in  this  way,  may  be  rapidly  increased  by  uterine  contrac- 
tions. Emmet  says  that  inversion  usually  takes  place 
between  the  birth  of  the  child  and  the  delivery  of  the 
placenta.  A  consideration  of  the  subject  of  acute  inver- 
sion following  labor  belongs  to  obstetrics.  It  is  very 
important  that  reduction  should  be  accomplished  im- 
mediately. The  delay  of  a  few  hours  greatly  increases 
the  difficulty  of  replacement.  Emmet  says:  "  The  uterus 
is  generally  well  contracted  in  twelve  hours,  and  with 
many  cases  it  would  be  then  quite  as  difficult  to  effect  a 
reduction  as  if  a  year  had  elapsed." 

If  the  placenta  is  still  attached  to  the  inverted  uterus, 
it  should  be  removed  before  reduction  is  attempted.  In- 
version of  the  uterus  when  seen  by  the  gynecologist  is 
usually  of  the  chronic  form.  It  has  existed  for  a  few 
weeks  or  for  several  years. 

Various  degrees  of  inversion  are  met  with.     Rarely 

260 


INVERSION  OF  THE  UTERUS. 


261 


inversion  of  one  horn  of  the  uterus  is  seen.  In  the  case 
of  fibroid  polyp  there  may  be  a  slight  depression  of  part 
of  the  uterine  wall,  resulting  from  local  atrophy  and 
traction.  In  other  cases  inversion  of  the  fundus  as  far  as 
the  internal  os  exists.  The  most  usual  condition  is  one 
of  complete  inversion,  in  which  the  body  of  the  uterus 
protrudes  from  the  external  os  into  the  vagina  (Fig.  138). 


Fig.  138. — Complete  inversion  of  the  uterus. 

The  cervix  may  or  may  not  be  inverted.  Sometimes  the 
inversion  is  complicated  by  vaginal  prolapse — or,  rather, 
by  inversion  of  the  vagina — so  that  the  whole  genital 
tract  becomes  turned  inside  out  and  protrudes  from  the 
vulva.  The  exposed  endometrium  becomes  congested 
and  bleeds  easily.  Ulceration  or  gangrene  may  result. 
If  the  inversion  is  extensive,  the  Fallopian  tubes  and 
the  ovaries  are  drawn  in  the  cup  formed  on  the  upper  as- 
pect of  the  uterus.  Intestines  or  omentum  may  also  lie 
in  this  cup.  In  cases  of  long  standing  the  rim  of  the 
cup  formed  by  the  muscular  cervix  becomes  very  much 
contracted,  and  adhesions  may  take  place  between  the 
peritoneal  surfaces.  These  complications  offer  great, 
sometimes  insurmountable,  difficulty  to  reduction  in  old 
cases. 


262      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Inversion  of  the  uterus  is  not  a  common  disease.  It  is 
very  rarely  seen  at  the  present  day. 

By  far  the  most  frequent  form  is  that  which  follows 
labor;  it  is  much  less  often  caused  by  fibroid  polyp.  It 
seems  especially  likely  to  occur  in  sarcoma  of  the  uterus. 


^j[^^H^>h-:^if '.  .^^M^v^ 


kf^. 


%\ 


Fig.  139. — Inversion  of  the  uterus  (Jeangons)  :  a,  mons  veneris;  c,  c,  nym- 
phse;  d,  clitoris;  e,  external  meatus;  g,  anterior  lip  of  cervix;  h,  h,  the  internal 
surface  of  the  uterus. 


The  symptoms  of  chronic  inversion  are  hemorrhage, 
discharge,  backache,  bearing-down  pains  in  the  pelvis, 
vesical  disturbance,  very  pronounced  anemia,  and  gen- 
eral physical  weakness.  Menstruation  is  very  much  in- 
creased in  amount,  and  intermenstrual  bleeding  may 
occur  after  standing  or  on  any  physical  effort. 

Inversion  of  the  uterus  very  rarely  exists  without  caus- 
ing serious  symptoms.  The  majority  of  unrelieved  cases 
end  fatally  from  anemia,   septicemia,  or  peritonitis.     A 


INVERSION  OF  THE  UTERUS.  263 

few  cases  of  spontaneous  reduction  and  cure  have  been 
recorded. 

The  diagfiiosis  of  recent  inversion  is  very  easy.  The 
body  of  the  uterus  usually  projects  into  the  vagina,  and 
the  placenta  may  be  found  attached  to  it.  The  abdomi- 
nal hand  fails  to  feel  the  rounded  body  of  the  uterus  in  the 
normal  position,  but  in  its  place  is  a  cup-shaped  hollow. 

Chronic  inversion  if  uncomplicated  by  other  lesion — 
e.  g.  a  uterine  tumor — may  also  be  readily  recognized  by 
careful  examination.  There  are,  however,  a  number  of 
cases  on  record  in  which  the  inverted  fundus  uteri  was 
amputated  in  mistake  for  a  fibroid  polyp. 

The  diagnosis  may  be  made  by  inspection,  bimanual 
examination,  and  the  uterine  sound. 

In  complete  inversion,  inspection  shows  a  round  tumor 
filling  the  vagina  or  protruding  from  the  vulva.  The 
tumor  is  covered  with  mucous  membrane,  perhaps  ulcer- 
ated in  places,  and  sometimes  partly  covered  with  strati- 
fied squamous  epithelium,  which  has,  as  a  result  of  irrita- 
tion, replaced  the  normal  epithelium  of  the  endometrium. 
It  is  of  a  deeper  red  color  than  a  pedunculated  fibroid. 
The  tumor  bleeds  easily.  In  the  only  case  of  inversion 
see'n  by  the  writer  the  orifices  of  the  Fallopian  tubes 
could  be  determined. 

Digital  examination  reveals  the  rounded  shape  of  the 
tumor  and  its  soft  character — softer  than  a  fibroid  polyp. 
The  tumor  may  be  so  soft  that  it  becomes  flattened  against 
the  posterior  vaginal  wall. 

The  tumor  is  found  to  be  free  on  all  sides  except  at  its 
upper  extremity,  where  there  is  a  pedunculated  attach- 
ment around  which  may  be  felt  the  more  or  less  attenu- 
ated cervix. 

If  the  cervical  canal  be  not  obliterated  by  adhesion  to 
the  neck  of  the  tumor,  the  finger  may  be  passed  upward, 
and  will  determine  that  the  mucous  membrane  is  reflected 
symmetrically  all  around  on  to  the  neck  of  the  tumor. 

Unless  the  woman  be  fat,  the  abdominal  hand  will 
determine  that  the  uterine  body  is  not  in  its  normal  posi- 


264      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

tion.  In  its  place  may  be  felt  the  cup-shaped  portion  of 
the  inverted  uterus. 

If  the  woman  be  fat,  the  rim  of  the  cup  may  be  felt 
by  palpation  through  the  rectum,  the  uterus  being  drawn 
down,  if  necessary,  by  a  tape  passed  around  the  upper 
portion  of  the  tumor. 

The  sound  passed  around  the  neck  of  the  tumor  will 
show  the  diminished  depth  of  the  uterine  cavity  and  the 
symmetrical  reflection  of  the  cervix  on  to  the  neck  of  the 
tumor. 

If  the  inversion  be  partial,  the  fundus  lying  still  above 
the  internal  os,  the  difficulty  of  diagnosis  becomes  much 
greater.  Examination  under  anesthesia  may  be  necessary, 
when  the  cup-shaped  depression  on  the  top  of  the  uterus 
may  be  detected,  and  dilatation  of  the  cervix  will  enable 
the  examiner  to  palpate  the  intra-uterine  tumor. 

The  differential  diagnosis  between  inversion  and  ute- 
rine polyp  is  made  by  determining,  in  the  latter  condition, 
that  the  body  of  the  uterus  lies  in  its  normal  relationship 
to  the  cervix,  and  that  the  upper  surface  is  not  cupped. 

The  sound  usually  passes  to  unequal  distances  around 
the  neck  of  a  fibroid  polyp,  unless  it  be  situated  symmet- 
rically in  the  centre  of  the  fundus.  The  depth  of  the 
uterus  in  the  case  of  uterine  polyp  is  usually  greater  than 
two  and  a  half  inches,  as  a  result  of  the  hypertrophy  that 
accompanies  polypi. 

It  is  said  that  if  the  sound  passes  to  a  less  depth  than 
two  and  a  half  inches  in  the  case  of  uterine  polyp,  ac- 
companying partial  inversion  of  the  uterus  should  be 
suspected. 

Treatment. — As  I  have  already  said,  an  inverted  ute- 
rus should  be  reduced  immediately  after  the  accident 
occurs.  If  this  is  not  done,  the  difficulties  of  reduction 
become  very  great.  Until  about  forty  years  ago,  reduc- 
tion in  chronic  cases  was  considered  to  be  impossible.  A 
considerable  variety  of  methods  of  reduction  have  been 
recommended.  Some  operators  advocate  reduction  by 
the  hands  alone;    others  advise  the  assistance  of  instru- 


INVERSION  OF  THE  UTERUS.  265 

ments;  and  others,  again,  the  employment  of  continuous 
elastic  pressure. 

The  woman  should  be  kept  in  bed  for  a  few  days  before 
the  operation.  Saline  laxatives  should  be  administered. 
The  parts  should  be  prepared  by  vaginal  injections  of  hot 
water  in  large  quantity,  administered  three  times  a  day. 
A  large  Barnes  bag  should  be  placed  in  the  vagina  for 
two  or  three  days  before  the  operation,  in  order  to  distend 
the  genital  tract  sufficiently  to  admit  the  hand.  In  some 
cases  the  pressure  of  such  a  bag,  applied  for  from  one  to 
eleven  days,  has  itself  effected  reduction.  At  the  time 
of  operation  an  anesthetic  should  be  administered  and 
the  woman  should  be  placed  in  the  lithotomy  position. 
The  bladder  should  be  emptied. 

The  hand  should  be  greased  before  introduction  into 
the  vagina.  Emmet  describes  the  method  of  reduction 
as  follows:  "My  hand  was  passed  into  the  vagina,  and, 
with  the  fingers  and  thumb  encircling  the  portion  of  the 
body  close  to  the  seat  of  inversion,  the  fundus  was 
allowed  to  rest  in  the  palm  of  the  hand.  This  portion 
of  the  body  was  firmly  grasped,  pushed  upward,  and  the 
fingers  were  then  immediately  separated  to  their  utmost; 
at  the  same  time  the  other  hand  was  employed  over  the 
abdomen  in  the  attempt  to  roll  out  the  parts  forming  the 
jring,   by  sliding  the  abdominal  parietes  over  its  edge. 


Fig.  140. — White's  repositor  for  inversion  of  the  uterus. 

This  manceuver  was  repeated  and  continued.  At  length, 
as  the  diameter  of  the  uterine  cervix  and  os  was  increased 
by  lateral  dilatation  with  the  outspread  fingers,  the  long 
diameter  of  the  body  of  the  uterus  became  shortened, 
.and   the    degree    of    inversion   proportionally   lessened. 


266     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


After  the  body  had  advanced  well  within  the  cervix, 
steady  upward  pressure  upon  the  fundus  was  applied  by 
the  tips  of  all  the  fingers  brought  together." 

The  reduction  may  be  aided  by  the  use  of  White's 
repositor  (Fig.  140).  This  instrument  consists  of  an 
india-rubber  cup  set  on  a  curved  iron  staff  which  has  at 
its  other  end  a  stout  spiral  spring.  The  cup  is  placed 
against  the  inverted  fundus,  and  the  spring  against  the 
body  of  the  operator,  who  is  thus  enabled  to  maintain 
continuous  pressure  during  the  manipulations  of  his 
fingers. 

Reduction  of  chronic  inversion  by  manual  methods  is 
a  long  and  exhausting  process,  requiring  sometimes  three 
or  four  hours  for  its  ac- 
complishment. It  is  ad- 
visable to  have  several  as- 
sistants for  mutual  relief 
It  may  be  necessary  to  de- 
sist, and  to  repeat  the  ope- 
ration when  the  condition 
of  the  patient  permits  it. 
In  case  the  reduction  can 
be  but  partially  accom- 
plished, or  when,  from 
any  cause,  the  attempt  at 
reduction  has  to  be  tem- 
porarily   abandoned,     the 

result  of  the  work  done  may  be  preserved  by  a  method 
of  Emmet's  of  freshening  the  edges  of  the  cervix  and 
bringing  them  into  apposition  by  suture  (Fig.  141). 
This  procedure  not  only  prevents  the  complete  inversion 
from  returning,  but  the  traction  produced  by  stretching 
the  cervix  over  the  fundus  itself  favors  reduction. 

Reduction  by  Contimioiis  Elastic  Pressure. — This 
method  is  employed  after  the  manual  method  has  failed, 
or  it  may  be  used  primarily.  As  has  been  said,  the 
gradual  pressure  of  a  Barnes  bag  has  in  several  instances, 
accomplished  reduction. 


Fig.   141. — Emmet's  method  of  retain- 
ing partially  reduced  inversion. 


INVERSION  OF  THE  UTERUS.  267 

The  most  efficient  instrument  for  maintaining  continu- 
ous pressure  consists  of  a  wooden  cup  set  on  a  stem  that 
extends  out  of  the  vagina.  Pressure  is  made  by  firm 
elastic  bands  attached  to  the  stem;  these  bands  pass,  two 
in  front  and  two  behind,  to  a  broad  abdominal  bandage. 
The  elastic  pressure  is  maintained  for  from  one  to  three 
weeks. 

The  parts  must  be  carefully  watched  for  sloughing. 
The  rim  of  the  cup  of  the  repositor  should  be  covered 
with  lint  saturated  with  carbolized  oil.  The  instrument 
should  be  removed  and  reapplied  every  day. 

The  direction  of  pressure  may  be  regulated  by  the 
tension  of  the  elastic  bands. 

If  inversion  accompany  a  uterine  polyp,  the  tumor 
should  be  removed;  and  if  the  inversion  is  not  spontane- 
ously corrected,  it  must  be  reduced. 

If,  after  careful  trial  of  conservative  methods,  reduc- 
tion of  an  inverted  uterus  is  found  to  be  impossible,  the 
physician  may  be  compelled  to  perform  hysterectomy. 


CHAPTER   XXIV. 
DISEASES  OF  THE  FALLOPIAN  TUBES. 

The  review  of  a  few  facts  about  the  anatomy  of  the 
Fallopian  tubes  will  assist  in  the  study  of  the  diseases 
that  affect  these  structures. 

The  average  length  of  the  normal  Fallopian  tube  is  4 
inches  (10  centimeters).  The  tubes  are  often  of  unequal 
length,  the  difference  sometimes  being  equal  to  i  centi- 
meter. The  length  of  the  Fallopian  tube  is  subject  to 
considerable  variation,  and  in  some  forms  of  ovarian  dis- 
ease the  length  of  the  tube  may  be  very  much  increased. 

The  uterine  end  of  the  tube  varies  in  thickness  from 
2  to  4  millimeters.  The  outer  end  varies  from  7  to  10 
millimeters  in  thickness. 

The  narrow  uterine  end  of  the  tube  is  called  the  isth- 
mus. The  outer  end,  of  trumpet-shape,  is  called  the 
ampulla.  The  canal  of  the  tube  is  small.  At  the  uterine 
end,  or  ostium  internum,  it  will  barely  admit  a  bristle. 
Beyond  the  middle  of  the  tube  the  canal  gradually  widens 
to  the  outer  opening — the  ostium  abdominale. 

The  ostium  abdominale  is  surrounded  by  peculiar 
luxuriant  folds  of  mucous  membrane  called  fimbriae. 
The  fimbriae  are  formed  by  the  outward  bulging  of  the 
exuberant  mucous  membrane. 

The  Fallopian  tube  consists  of  three  coats,  the  peri-, 
toneal,  the  muscular,  and  the  mucous. 

The  peritoneal  coat,  which  invests  the  tube  for  two-> 
thirds  of  its  circumference,  is  formed  by  the  free  bordei 
of  the  broad  ligament,  between  the  folds  of  which  the 
Fallopian  tube  lies.  Loose  connective  tissue  attaches  the 
peritoneal  to  the  middle  or  muscular  coat. 

268 


DISEASES  OF  THE  FALLOPIAN  TUBES.        269 

The  muscular  coat  consists  of  unstriped  muscular  fiber 
which  is  continuous  with  that  of  the  uterus.  The  mus- 
cular fibers  are  arranged  in  two  layers,  an  outer  longitu- 
dinal and  an  inner  circular  layer. 

The  inner  or  mucous  coat,  which  is  continuous  with 
the  mucous  membrane  of  the  uterus,  is  covered  with 
columnar  ciliated  epithelium. 


'.f^«  tin.* 


Fig.  142. — Section  of  the  normal  Fallopian  tube  near  the  uterine  cornu  (Beyea). 

In  the  outer  portion  of  the  tube  the  mucous  membrane 
is  thrown  into  longitudinal  folds  or  plicae.  These  folds 
increase  in  thickness  and  in  number  as  the  ostium  ab- 
dominale  is  approached.  The  difference  in  the  degree 
of  plication  at  the  two  ends  of  the  tube  is  shown  by- 
Figs.  142,  143.  The  folds  of  mucous  membrane  project 
beyond  the  ostium  to  form  the  fimbriae.  Like  the  rest 
of  the  mucous  membrane,  the  fimbriae  are  covered  by 
columnar  ciliated  epithelium. 

The  peritoneal  covering  does  not,  as  a  rule,  extend  on 


270      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

to  the  fimbriae.  It  terminates  by  a  sharp  line  which 
marks  also  the  termination  of  the  circular  muscular  fibers 
of  the  middle  coat  of  the  tube.  The  fimbriae  are  subject 
to  great  variation  in  number  and  in  distribution.     Some- 


Fig.   143. — Section  of  the  normal  Fallopian  tube  near  the  abdominal  ostium 

(Beyea). 

times  the  Fallopian  tube  has  one  or  two  accessory  ostia 
in  the  vicinity  of  the  usual  opening.  These  accessory  ostia 
are  situated  on  the  upper  aspect  of  the  tube  and  are  sur- 
rounded by  more  or  less  luxuriant  fimbriae.  Occasionally 
a  small  pedunculated  tuft  of  fimbriae  is  found  on  the 
outer  portion  of  the  tube  (Fig.  144,  B).     In  some  cases 


DISEASES  OF  THE  FALLOPIAN  TUBES.        271 


Fig.  144.— Fallopian  tube  and  ovary  :    A,  accessory  tubal  end  with  an  ostium  ; 
B,  pedunculated  tuft  of  fimbriae. 

there  is  an  accessory  tubal  end  supplied  with  an  ostium 
(Fig.  144,  A). 


Fig.  145. — Fallopian  tube,  ovaiy,  and  parovarium:  a,  hydatid  of  Morgagni; 
b,  cyst  of  Kobelt's  tube ;  c,  Gartner's  duct. 

Very  often  a  small  pedunculated  cyst,  about  the  size 
of  a  pea,  is  found  attached  to  the  fimbriae  or  to  the  outer 
aspect  of  the  tube. 


272      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

These  cysts  are  called  hydatids,  or  cysts  of  Morgagni. 
They  are  said  to  occur  in  about  8  per  cent,  of  adults  and 
in  20  per  cent,  of  fetuses.    They  are  not  pathological. 

The  cyst  wall  is  composed  of  three  coats:  an  external 
peritoneal  coat;  a  middle  muscular  coat,  arranged  in  two 
layers;  and  an  inner  mucous  coat  covered  with  columnar 
ciliated  epithelium.  The  cyst  contains  a  clear  watery 
fluid. 

No  distinct  glands,  such  as  are  found  in  the  cervix  and 
the  body  of  the  uterus,  have  been  observed  in  the  Fallo- 
pian tubes.  The  mucous  crypts  formed  by  the  folds  of 
the  mucous  membrane  are  probably  glandular  in  character 
and  secrete  an  albuminous  fluid. 

INFLAMMATION  OF  THE  FALLOPIAN  TUBES,    OR   SALPIN- 
GITIS. 

Inflammation  is  the  disease  that  most  usually  affects 
the  Fallopian  tubes.  The  condition  is,  as  a  rule,  second- 
ary to  endometritis,  the  mucous  membrane  of  the  tubes 
becoming  inflamed  by  direct  extension  from  the  mucous 
membrane  of  the  uterus. 

The  causes  of  salpingitis  are  as  numerous  as  those  of 
endometritis.  The  most  common  causes  of  salpingitis  are 
sepsis  and  gonorrhea. 

Any  form  of  inflammation  of  the  endometrium  may 
extend  to  the  Fallopian  tubes,  but  the  septic  and  the 
gonorrheal  forms  of  endometritis  are  especially  virulent, 
and  it  is  the  rule  in  these  diseases  that  the  tubes  are 
affected. 

The  various  forms  of  glandular  and  interstitial  endo- 
metritis that  have  already  been  described,  and  which  are 
due  to  subinvolution,  laceration  of  the  cervix,  uterine 
displacements,  fibroid  tumors,  etc.,  may  exist  for  along 
time  without  producing  any  perceptible  disease  of  the 
tubes.  In  sepsis  and  gonorrhea,  however,  the  tubes  be- 
come very  quickly  affected  after  the  uterine  cavity  has 
been  invaded,  and  for  this  reason  these  forms  of  endome- 
tritis excite  the  greatest  apprehension. 


DISEASES  OF  THE  FALLOPIAN  TUBES.        273 

Ivike  inflammation  of  other  structures,  salpingitis  may 
be  either  acute  or  chronic. 

Acute  Salpingitis. — In  the  first  stages  of  acute  sal- 
pingitis the  disease  is  confined  to  the  mucous  membrane 


Xi- 

\ 


Y\G.    146. — Acute  septic  salpingitis :    section  about   the  middle   of  the   tube 

(Beyea). 

of  the  tube.  It  very  quickly  extends  thence,  however, 
to  the  muscular  and  peritoneal  coats,  which  become  infil- 
trated with  embryonic  cells  characteristic  of  the  early 
stages  of  inflammation  (Fig.  146). 

If  the  tube  is  laid  open,  the  mucous  membrane  is  found 

18 


274      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

covered  with  a  muco-purulent  secretion.  The  whole 
tube  is  soft,  succulent,  and  friable.  The  friability  is 
such  that  the  tube  may  readily  be  ruptured  by  bending. 
The  fimbriae  are  swollen  and  congested.  A  drop  of  pus 
is  often  seen  exuding  from  the  ostium  abdominale. 

In  acute  salpingitis  the  tube  may  become  very  quickly 
(in  a  week  or  ten  days)  enlarged  to  the  size  of  the  index 
finger  or  the  thumb. 

The  condition  that  has  been  described  is  that  found  in 
the  severe  cases  of  acute  salpingitis,  the  result  of  gonor- 
rhea or  of  sepsis  after  labor.  Opportunity  is  afforded  to 
examine  such  cases  when  the  woman  has  been  subjected 
to  celiotomy,  or  at  the  post-mortem  when  the  woman  has 
died  of  acute  peritonitis  or  sepsis. 

It  is  probable  that  a  good  many  cases  of  acute  salpin- 
gitis undergo  resolution,  and  that  the  tube  is  restored  to 
its  normal  condition. 

It  is  also  probable  that  milder  forms  of  acute  salpin- 
gitis occur — cases  in  which  the  disease  is  limited  to  the 
mucous  membrane  and  is  merely  catarrhal  in  character, 
there  being  no  pus,  but  a  hypersecretion  of  mucus  from 
the  tube-lining.  Such  cases,  however,  recover  or  pass 
into  a  chronic  form  of  simple  catarrhal  salpingitis  ;  and 
the  diagnosis  made  by  a  study  of  the  subjective  and  ob- 
jective symptoms  cannot  be  confirmed  by  operation  or 
autopsy. 

Resolution  with  perfect  restoration  of  the  Fallopian  tube 
to  its  normal  condition  is,  of  course,  always  to  be  hoped 
for.  In  some  cases  a  few  fine  peritoneal  adhesions  be- 
tween the  tube  and  neighboring  structures — such  as  the 
ovary,  the  uterus,  the  anterior  or  the  posterior  surfaces 
of  the  broad  ligament,  or  a  loop  of  intestine — may  result 
before  resolution  takes  place,  and  persist  after  all  other 
traces  of  inflammation  have  disappeared.  In  other  cases 
cure  may  result,  after  a  greater  or  less  degree  of  perma- 
nent damage  has  been  done  to  the  abdominal  ostium  of 
the  tube,  by  the  shrinking  and  distortion  or  crumpling  of 
the  fimbriae.      Such  indications  of  an  old,  cured  attack 


DISEASES  OF  THE  FALLOPIAN  TUBES.        275 

of  salpingitis  are  not  infrequently  seen  during  celiotomy 
for  other  conditions. 

When  resolution  and  cure  do  not  occur,  a  speedy  fatal 
result  may  take  place  by  direct  extension  of  the  infection 
from  the  tube  to  the  general  peritoneum,  with  the  pro- 
duction of  general  peritonitis.  Between  this  extreme 
and  the  mild  forms  of  very  localized  peritonitis,  marked 
by  a  few  harmless  adhesions,  all  degrees  may  exist. 
Sometimes  a  local  accumulation  of  pus  occurs  in  the 
pelvis,  walled  off  from  the  general  peritoneum  by  rapidly 
formed  adhesions.  In  other  cases  a  tubal  abscess  is 
quickly  formed  by  inflammatory  closure  of  the  abdom- 
inal ostium  and  distention  of  the  tube  with  pus;  or  the 
cellular  tissue  of  the  broad  ligament  may  become  in- 
fected, and  the  abscess  may  originate  there.  And, 
finally,  if  the  woman  escape  these  dangers,  one  or  other 
of  the  various  forms  of  chronic  salpingitis  may  result, 
and  render  her  a  lifelong  invalid. 

Chronic  Salpingitis.— Salpingitis  is  usually  seen  in 
the  chronic  form.  An  acute  primary  salpingitis  must 
not  be  confounded  with  an  acute  attack  of  inflammation 
or  with  an  acute  exacerbation  in  an  old  chronic  case.  It 
is  rare  that  acute  gonorrheal  salpingitis  is  seen.  The 
disease  is  usually  subacute  or  chronic  from  the  begin- 
ning, as  are  many  of  the  other  manifestations  of  gonor- 
rhea in  woman,  like  gonorrheal  cervicitis  and  endometri- 
tis. The  most  frequent  form  of  acute  salpingitis  met  with 
is  the  septic  variety,  which  occurs  as  a  result  of  septic 
infection  after  a  criminal  abortion,  a  miscarriage,  or  a 
labor.  It  is  usually  complicated  by  severe  septic  endo- 
metritis, peritonitis,  or  general  sepsis. 

The  lesions  found  in  chronic  salpingitis  are  numerous. 
The  simplest  form  of  the  disease  is  the  chronic  catarrhal 
salpingitis,  in  which  the  pathological  changes  are  con- 
fined to  the  mucous  membrane  of  the  tube.  The  mus- 
cular and  peritoneal  coats  are  not  affected.  The  ostium 
abdominale  remains  open  and  is  of  the  normal  shape. 
The   mucous   membrane    is    congested.      The   folds    of 


276      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

mucous  membrane,  or  the  plicae,  are  hypertrophied  from 
gradual  infiltration  of  inflammatory  products.  The  tube 
may  become  somewhat  enlarged  and  more  tortuous  than 
normal.  If  the  inflammatory  condition  extends  to  the 
middle  or  muscular  coat  of  the  tube,  the  interstitial 
form  of  salpingitis  is  produced.  The  wall  of  the  tube 
becomes  thicker  and  harder.  The  microscope  shows  an 
increased  amount  of  connective  tissue  in  the  tube-wall. 

As  chronic  salpingitis  progresses  the  ciliae  of  the  lining 
cells  disappear. 

If  the  disease  extends  through  the  peritoneal  coat,  in- 
flammatory adhesions  take  place  between  the  tube  and 
neighboring  structures.  The  tube  is  often  found  adherent 
to  the  posterior  aspect  of  the  uterus,  the  broad  ligament, 
or  the  ovary. 

The  most  usual  seat  of  adhesions  is  about  the  abdominal 
ostium.  Adhesions  here  are  caused  by  leakage  or  escape 
of  septic  material  into  the  peritoneal  cavity.  The  leak- 
age is  slow,  and  the  gradually  formed  adhesions  in  time 
close  the  ostium  by  gluing  it  to  adjacent  structures,  so 
that  further  escape  of  tubal  contents  by  this  opening  is 
stopped. 

If,  in  such  a  case,  the  tube  is  freed  from  its  adhesions, 
the  fimbriae  will  be  found  in  the  normal  position  with  the 
ostium  abdominale  open. 

The  usual  method  of  closure  of  the  distal  end  of  the 
Fallopian  tube  is  by  another  process.  It  takes  place  as 
follows:  When  the  inflammation  reaches  the  muscular 
coat  of  the  tube,  this  coat  becomes  lengthened  and  ex- 
tends beyond  the  fimbriae,  which  apparently  retract  and 
become  invaginated  in  the  tube.  The  opening  of  the 
tube,  instead  of  being  flaring  with  protruding,  diverg- 
ing fimbriae,  becomes  rounded  and  narrow  (Fig.  147). 
The  fimbriae  become  drawn  farther  into  the  tube  until 
they  appear  to  be  directed  inward  instead  of  outward. 
The  ostium  becomes  narrower,  and  more  rounded, 
until  the  edges  finally  meet  and  unite  by  peritoneal 
adhesions. 


DISEASES  OF  THE  FALLOPIAN  TUBES.        277 

Tubes  representing  all  stages  of  this  process  of  closure 
are  often  found  in  operating  for  inflammatory  disease. 

Closure  of  the  abdominal  ostium  by  any  method  is  to 
be  viewed  as  a  conservative  process.  It  prevents  leakage, 
through  this  channel,  of  septic  material,  and  consequently 
diminishes  the  danger  of  peritonitis. 

When  the  abdominal  ostium  has  become  closed,  the 
tubal  contents  and  secretions  may  have  a  sufficient 
passage  for  escape  by  the  isthmus  into  the  uterus,  and 
no  further  changes  take  place  beyond  slow  infiltration 


Fig.  147. — Salpingitis  with  partial  inversion  of  the  fimbrise. 


and  degeneration  of  the  tube-walls.  The  tube  may  be- 
come much  hypertrophied,  not  from  distention  of  the 
lumen,  but  as  the  result  of  simple  inflammatory  infiltra- 
tion of  the  mucous  and  muscular  coats,  and  may  attain 
the  size  of  the  thumb.  The  walls  may  become  much 
degenerated,  soft,  and  friable,  so  that  the  tube  may  easily 
be  cut  through  b}^  a  ligature  or  may  be  broken  by  bending. 
The  whole  tube  may  become  much  elongated  and  very 
tortuous,  reaching  a  length  of  six  or  eight  inches.  The 
isthmus  of  the  tube,  or  the  portion  in  immediate  relation 
to  the  uterus,  is  usually  least  affected.  The  whole  tube 
may  become  much  hypertrophied,  and  yet  the  isthmus 
will  remain  approximately  of  its  normal  size.     In  other 


278      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

cases,  however,  the  disease  extends  throughout  the  whole 
length  of  the  tube  into  the  uterine  horn,  and  the  degen- 
eration of  the  tube  may  be  such  that  it  may  readily  be 
broken  off  at  its  junction  with  the  uterus. 

If,  after  the  ostium  abdominale  has  been  closed,  any- 
thing occurs  to  obstruct  the  escape  of  the  tubal  contents 
into  the  uterus,  cystic  distention  of  the  tube  will  take 
place.  Such  obstruction  may  be  produced  by  swelling 
of  the  mucous  membrane  in  the  narrow  isthmus;  by  cica- 
tricial contraction;  or  by  a  sharp  flexure  in  any  part  of 
the  tortuous  tube.  Sometimes  there  are  two  or  more 
distended  portions  of  the  same  tube. 

When  the  tube  is  distended  with  pus,  the  condition  is 
called  a  pyosalpinx;  when  distended  with  a  watery  fluid, 
a  hydrosalpinx;  and  when  distended  with  blood,  a  he- 
inatosalpmx. 

Tubal  cysts  of  this  kind  may  attain  large  size,  in  some 
cases  equal  to  that  of  the  fetal  head. 

The  shape  of  the  tube  becomes  much  altered.  The 
greatest  distention  is  at  the  distal  portion,  so  that  the 
tube  assumes  a  pear-shape.  The  lower  portion  of  the 
tube  is  restrained  by  the  mesosalpinx  and  the  tubo-ova- 
rian  ligament,  so  that  as  the  tube  increases  in  length  the 
upper  portion  appears  to  outgrow  the  lower,  and  a  retort- 
shaped  tumor  results,  or  the  tube  may  become  tortuous 
and  folded  upon  itself. 

As  the  tube  enlarges  the  layers  of  the  mesosalpinx 
may  become  separated,  and  the  tube  burrows  between 
them  until  it  is  brought  into  immediate  contact  with  the 
ovary,  and  the  retort-shaped  tumor  appears  with  the  ovary 
lying  in  the  concave  portion. 

In  some  cases  the  ovary  and  the  tube  become  adherent 
by  peritoneal  adhesions,  and  the  mesosalpinx,  which  is 
wrinkled  and  folded  between  them,  may  be  restored  by 
separation  of  the  adhesions. 

In  other  cases  the  mesosalpinx  itself  becomes  much 
thickened  by  inflammatory  infiltration,  and  keeps  the 
tube  and  ovary  separated. 


DISEASES  OF  THE  FALLOPIAN  TUBES.        279 

In  chronic  salpingitis  the  inflammatory  process  usu- 
ally in  time  extends  to  the  ovary,  and  some  of  the  forms 
of  chronic  ovaritis  are  produced. 

The  capsule  of  the  ovary  becomes  thickened,  and  rup- 
ture of  the  ripe  ovarian  follicles  is  prevented.  Small 
cysts  throughout  the  ovary  are  formed  in  this  way.'  Two 
or  more  cysts  may  become  converted  into  one  cavity  by 
absorption  of  the  intervening  walls,  so  that  cystic  spaces 
of  larger  size,  equal  to  that  of  a  duck-egg,  may  result. 
Such  cysts  may  become  infected  by  pyogenic  organisms 
from  the  tube,  and  an  ovarian  abscess  is  produced. 

Tubo-ovarian  Abscess. — If  the  tube  is  brought  into 
immediate  contact  with  the  ovary,  either  by  agglutina- 


Tubo-ovarian  abscess. 


tion  of  the  fimbriated  end  to  the  surface  of  the  ovary,  or 
by  adhesion  of  the  side  of  the  tube  to  the  ovary,  or  by 
burrowing  between  the  layers  of  the  broad  ligament,  the 
tissue  intervening  between  the  cavity  of  the  tube  and 
the  cyst  of  the  ovary  may  be  absorbed  or  perforated,  and 
the  two  cavities  will  be  thrown  into  one,  forming  a 
tubo-ovarian  abscess  or  a  tubo-ovarian  cyst  (Fig.  148). 
The  opening  between  the  tubal  and  ovarian  portions  of 
the  cyst  does  not  usually  correspond  to  the  abdominal 


28o      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

ostium  of  the  tube,  but  may  be  an  adventitious  opening 
in  the  side  of  the  tube  (Fig.  148). 

Pyosalpinx. — When  the  Fallopian  tube  is  distended 
with  pus  or  with  other  fluid,  its  walls  gradually  become 
thinned.  In  this  respect  the  Fallopian  tube  differs  from 
the  body  of  the  uterus,  in  which  a  hypertrophy  of  the 
muscular  coat  usually  takes  place,  under  the  influence  of 
distention  from  the  presence  of  retained  fluid  within  it. 

This  gradual  thinning  of  the  tube-wall  predisposes  to 
rupture  or  leakage  and  the  escape  of  the  contents  into 
the  abdominal  cavity.  A  pyosalpinx  often  becomes  ad- 
herent to  the  rectum,  the  small  intestine,  or  the  bladder. 
The  wall  of  the  intestine  or  the  bladder  becomes  perfor- 
ated, and  the  pus  is  discharged  in  this  way.  It  seems 
probable  that  in  some  unusual  cases  the  obstruction  in 
the  lumen  of  the  tube  is  temporarily  overcome,  and  that 
evacuation  takes  place  through  the  uterus,  followed  by 
refilling  of  the  tube.  This,  however,  is  a  very  unusual 
occurrence,  and  is  not  frequent,  as  is  assumed  by  some 
writers.  The  evidence  of  such  discharge  is  based  only  on 
clinical  observation.  There  is  no  good  pathological  evi- 
dence of  such  an  occurrence.  It  is  probable  that  in  most 
of  the  reported  cases  the  purulent  or  watery  discharge 
which  escaped  in  a  sudden  gush  was  derived  from,  and 
had  been  retained  in;  the  body  of  the  uterus. 

The  pus  of  pyosalpinx  varies  greatly  in  character.  In 
the  early  stages  of  the  disease  it  is  actively  septic  and 
contains  a  variety  of  micro-organisms. 

These  organisms  are  the  gonococcus,  streptococcus, 
staphylococcus,  the  bacillus  coli  communis,  the  tubercle 
bacillus,  and  the  pneumococcus. 

In  the  later  stages,  however,  these  organisms  become 
inert,  die,  and  disappear,  so  that  in  the  majority  of  cases 
of  chronic  pyosalpinx  the  pus  is  found  to  be  bacterio- 
logically  sterile.  Observation  on  this  subject  made 
by  a  number  of  investigators  shows  that  out  of  133 
cases  of  acute  and  chronic  suppuration  of  the  uterine  ap- 
pendages in  which  the  pus  was  examined  bacteriologi- 


DISEASES  OF  THE  FALLOPIAN  TUBES.        281 

cally,  no  organisms  whatever  were  found  in  82  cases;  in 
other  words,  the  pus  was  sterile  in  about  61  per  cent,  of 
the  cases.  The  pyosalpinx  in  time,  therefore,  becomes 
inert  so  far  as  any  active  inflammatory  action  is  concerned, 
and  resembles  a  chronic  abscess  in  other  parts  of  the  body. 
Active  inflammatory  action  may,  however,  be  excited  at 
any  time,  as  in  other  chronic  abscess,  by  a  new  infection, 
septic  organisms  entering  the  abscess  by  way  of  the  ute- 
rine cavity,  an  adherent  loop  of  intestine,  or  the  bladder. 
The  woman  will  then  have  an  attack  of  acute  septic  in- 
flammation in  the  old  pyosalpinx,  and  will  be  exposed  to 


Fig.  149. — Hydrosalpinx,  showing  complete  inversion  of  the  fimbrise. 

the  various  dangers  that  were  imminent  during  the  pri- 
mary acute  stages  of  the  disease. 

It  seems  probable  that  if  the  woman  survive  the  dan- 
gers to  which  she  is  exposed  from  a  pyosalpinx,  the 
tumor  may  in  time  become  converted  into  a  hydrosal- 
pinx. The  solid  constituents  of  the  fluid  become  ab- 
sorbed or  deposited  upon  the  cyst-walls,  and  a  clear 
watery  fluid  remains.  In  hydrosalpinx  the  recesses  of 
the  tube  are  often  found  to  contain  cheesy  material  and 
cholesterin — remnants  of  the  old  purulent  accumulation. 
The  tubo-ovarian  cyst  is  formed  in  this  way  from  a  former 
tubo-ovarian  abscess. 

Hydrosalpinx. — The  fluid  in  a  hydrosalpinx  may  be 


282      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

colorless,  slightly  yellow,  or  brownish  or  chocolate 
colored  from  the  presence  of  blood.  As  the  accumula- 
tion increases,  the  walls  of  the  cyst  atrophy  and  become 
very  thin.  The  epithelium  and  the  mucous  membrane 
atrophy  and  in  time  disappear,  until  nothing  but  a  thin- 
walled  transparent  cyst  remains  (Fig.  149).  The  cyst- 
wall  in  hydrosalpinx  is  always  thinner  and  more  trans- 
parent than  that  in  pyosalpinx.  On  the  inner  wall  of 
the  cyst  delicate  ridges  corresponding  to  the  plicae  or 
folds  of  mucous  membrane  may  be  traced.  There  may 
often  be  discovered,  at  the  distal  end  of  the  retort-shaped 
tumor,  a  slight  depression  that  marks  the  position  of  the 
abdominal  ostium,  while  upon  the  inner  aspect  of  this 
depression  may  be  found  the  remains  of  the  invaginated 
fimbriae.  The  size  of  the  tube  in  hydrosalpinx  varies 
from  that  of  the  little  finger  to  a  tumor  as  large  as  the 
fetal  head.  Large  hydrosalpinx  tumors  are  very  unusual, 
because  the  fluid  probably  leaks  slowly  through  the  thin 
cyst- wall,  and  because  the  secreting  surface  of  the  cyst 
becomes  destroyed  by  pressure.  The  fluid  from  a  hydro- 
salpinx is  sterile,  unirritating  to  the  peritoneum,  and  is 
readily  absorbed.  The  cyst  may  rupture  spontaneously 
or  as  the  result  of  some  slight  accident;  the  fluid  will  be 
absorbed  by  the  peritoneum,  and  only  the  shrivelled, 
atrophied  sac  will  remain.  In  old  cases  of  this  kind  the 
Fallopian  tube  is  represented  by  an  impervious  cord. 
Such  specimens  have  often  been  found  in  old  prostitutes 
who  have  survived  the  dangers  of  their  calling. 

Hematosalpinx. — True  hematosalpinx,  a  closed  Fal- 
lopian tube  distended  with  blood,  is  a  rare  condition. 
Tubal  pregnancy  is  the  usual  cause  of  an  accumulation 
of  blood  in  the  Fallopian  tube,  but  the  term  hematosal- 
pinx should  not  be  applied  to  this  condition.  True 
hematosalpinx  occurs  when,  from  any  cause,  hemorrhage 
takes  place  into  a  tube  that  had  previously  been  closed 
by  inflammatory  action.  Such  an  accident  may  be  caused 
by  traumatism  or  by  torsion  of  the  pedicle  of  a  tubal  cyst. 
Slight  hemorrhages  of  this  kind  occur  in  pyosalpinx  and 


DISEASES  OF  THE  FALLOPIAN  TUBES.        283 

in  hydrosalpinx,  and  cause  the  brownish  discoloration 
that  is  sometimes  seen  in  the  contents  of  these  tumors. 

The  various  forms  of  inflammatory  disease  of  the  tubes 
that  have  been  described  under  names  which  designate 
the  gross  appearance  of  the  disease  are  all  really  but  dif- 
ferent manifestations  of  the  same  primary  condition. 
Gonorrheal  or  septic  infection  may  produce  any  of  the 
forms  of  tubal  disease  that  have  been  mentioned.  Inter- 
stitial salpingitis  without  closure  of  the  ostium,  pyosal- 
pinx,  hydrosalpinx,  hematosalpinx,  tubo-ovarian  abscess, 
etc.  are  not  distinct  diseases,  but  are  different  manifesta- 
tions of  the  same  disease,  representing  different  stages  of 
progress  or  different  methods  of  development.  Several 
of  these  different  forms  are  often  found  in  the  same 
woman.  On  one  side  there  may  be  a  hydrosalpinx,  on 
the  other  a  pyosalpinx,  both  caused  by  a  primary  chronic 
gonorrhea;  the  distal  end  of  one  tube  may  be  distended 
by  a  clear  watery  fluid,  forming  a  hydrosalpinx,  while  the 
isthmus  may  be  distended  with  pus,  forming  a  pyosal- 
pinx; a  hematosalpinx  may  be  formed  on  one  side,  while 
a  tubo-ovarian  abscess  exists  on  the  other;  and  so  through 
a  great  variety  of  combinations. 

Pyosalpinx  with  active  septic  contents  represents  the 
early  stages  of  tubal  disease,  or  it  represents  a  chronic 
condition  in  which  reinfection  has  occurred.  Pyosalpinx 
with  sterile  pus  is  like  a  chronic  abscess  anywhere  else, 
and  represents  a  chronic  form  of  salpingitis  that  had  been 
active  and  purulent  in  the  beginning.  Hydrosalpinx 
represents  the  disease  less  violent  and  septic  in  the  begin- 
ning, and  slow  in  progress;  or  it  represents  the  last  stages 
of  an  old  pyosalpinx ;  while,  finally,  hematosalpinx  rep- 
resents a  condition  of  salpingitis  in  which  some  accident 
has  befallen  the  cystic  tube  and  caused  hemorrhage  into 
its  cavity. 

The  description  given  shows  the  progress,  the  dangers, 
and  the  terminations  of  salpingitis. 

The  disease  is  caused  by  extension  of  inflammation 
from  the  endometrium.     The  usual  causes  of  this  inflam- 


284      A    TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

mation  are  gonorrhea,  or  infection  after  a  criminal  abor- 
tion, a  labor,  or  a  miscarriage.  The  gonorrheal  salpin- 
gitis is  usually  slow  or  insidious  from  the  beginning. 
The  symptoms  of  the  disease'  are  often  not  troublesome 
until  many  months  after  the  primary  gonorrheal  infec- 
tion. The  closure  of  the  tube  is  slow,  and  it  is  some- 
times not  until  the  tube  becomes  distended  with  pus  that 
the  woman  experiences  much  suffering  and  is  placed  in 
imminent  danger.  There  are  cases,  however,  of  acute 
gonorrheal  salpingitis  in  which  the  disease  is  virulent 
and  active  from  the  beginning.  Infection  may  traverse 
the  tube,  reach  the  peritoneum  through  the  open  ostium, 
and  produce  general  peritonitis  within  a  few  days  of  the 
primary  attack  of  gonorrhea.  In  such  cases  it  is  prob- 
able that  the  infection  is  a  mixed  one,  other  organisms 
accompanying  the  gonococcus.  In  other  cases  the  ab- 
dominal ostium  becomes  quickly  closed  and  a  gonorrheal 
tubal  abscess  is  rapidly  formed. 

The  septic  variety  of  salpingitis,  as  has  already  been 
said, is  more  frequently  acute  from  the  beginning.  With- 
in ten  days  or  two  weeks  after  a  criminal  abortion,  or  after 
a  miscarriage  or  labor,  a  large  tubal  abscess  may  be 
formed;  or  the  septic  organisms  may  pass  through  the 
tube  before  the  ostium  has  been  closed,  and  produce  with- 
in a  few  days  a  general  fatal  peritonitis. 

On  the  other  hand,  septic  salpingitis  is  often  slow,  a 
mild  attack  of  puerperal  sepsis  being  the  beginning  of 
years  of  invalidism,  of  gradually  increasing  suffering, 
until  gross  tubal  disease  is  produced. 

The  slowest  forms  of  salpingitis  are  those  that  result 
from  chronic  endometritis,  such  as  accompanies  subinvo- 
lution, laceration  of  the  cervix,  retro-displacements,  or 
uterine  fibroid.  Simple  catarrhal  salpingitis  is  often  found 
in  these  diseases;  or  the  abdominal  ostium  may  be  closed, 
and  a  small  hydrosalpinx  will  be  present;  or  the  isthmus 
may  be  sufficiently  open  for  drainage,  and  no  tubal  dis- 
tention result.  Hydrosalpinx  is  very  often  found  with 
uterine  fibroids. 


DISEASES  OF  THE  FALLOPIAN  TUBES.        285 

Cancer  of  the  cervix  or  the  body  of  the  uterus  is  a  fre- 
quent cause  of  salpingitis,  of  hydrosalpinx,  and  of  pyo- 
salpinx.  The  endometrial  inflammation  secondary  to  the 
cancer  extends  into  the  tubes. 

The  progress  of  salpingitis  is  beset  with  danger. 

At  any  time  a  pyosalpinx  may  rupture  and  a  rapid  fatal 
peritonitis  result.  Unusual  effort,  vaginal  examination, 
or  slight  operations  upon  the  cervix  or  body  of  the  ute- 
rus may  cause  this  accident.       Not  infrequently,   such 


Fig.  150. — Chronic  salpingitis  with  general  adhesions   of  tubes,  ovaries,  and 
uterus  (Bandl). 


rupture  has  been  produced  by  even  gentle  bimanual  ex- 
amination. I  have  seen  a  fatal  peritonitis  occur  from 
rupture  of  a  pyosalpinx  during  the  replacement  of  a  pro- 
lapsed uterus. 

For  this  reason  the  operator  should  always  determine 
by  careful  examination  the  presence  or  absence  of  tubal 
disease  in  every  case  before  performing  any  of  the  minor 
gynecological  operations  or  manipulations,  such  as  tra- 
chelorrhaphy or  the  replacement  of  a  retroverted  uterus. 


286      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Purulent  disease  of  the  tubes  is  a  contraindication  to  all 
sucli  procedures,  unless  an  immediate  subsequent  celiot- 
omy is  to  be  performed.  Great  care  must  be  exercised 
in  any  of  the  less  dangerous  forms  of  salpingitis.  In 
any  case  of  salpingitis,  however  mild,  an  acute  attack 
may  be  excited  by  reinfection  or  by  rough  manipulation. 
Rupture  into  the  peritoneum  is  not  the  only  danger  to 
which  the  woman  is  exposed  in  salpingitis.  The  gradu- 
ally formed  adhesions  in  the  pelvis  impede  the  motion  of 
the  pelvic  intestines  and  may  cause  intestinal  obstruc- 


FlG.  151. — Chronic  salpingitis:  both  Fallopian  tubes  are  closed  and  adherent. 


tion.  Obstruction  of  the  ureters  has  occurred  from  pel- 
vic inflammation.  The  Fallopian  tube  ma}^  discharge 
its  contents  through  the  bladder  and  produce  violent  cys- 
titis, or  it  may  discharge  through  the  rectum  or  intestine, 
or  adhere  to  the  side  of  the  vagina  and  discharge  through 
this  channel;  or  it  may  be  evacuated  through  the  abdom-- 
inal  parietes.  Such  fistulous  openings  rarely,  if  ever, 
close  spontaneously  and  permanently.  Temporary  clos- 
ure may  occur,  but  the  tube  will  refill  and  discharge  as 
before. 

Fistulse  of  this  kind  persist  for  many  years,  becoming 


DISEASES  OF  THE  FALLOPIAN  TUBES.        287 

seats  of  tuberculosis  or  exhausting  the  woman  by  the 
continuous  suppuration. 

If  the  patient  escape  these  dangers,  the  disease  may 
become  quiescent.  Some  of  the  less  dangerous  forms  of 
salpingitis  are  produced,  until  finally,  when  the  woman 
has  reached  middle  life,  a  hydrosalpinx  remains,  or  an 
adherent,  atrophied,  cord-like  remnant  of  the  tube. 
Though  then  freed  from  the  various  dangers  that  had 
threatened  her  life,  she  is  not  restored  to  health,  but 
remains  a  suffering  invalid. 

Salpingitis  may  be  unilateral  or  bilateral.  It  is  more 
likely  to  be  unilateral  in  the  acute  cases  than  in  the 
chronic,  for,  as  the  primary  focus  of  the  disease  exists  in 
the  body  of  the  uterus,  it  will  extend  in  time  to  the  sec- 
ond tube  in  case  only  one  had  at  first  been  involved.  If 
the  endometrial  disease  is  cured  before  the  second  tube 
has  been  attacked,  the  salpingitis  may  remain  unilateral. 
Double  salpingitis  is  especially  likely  to  occur  in  those 
diseases  of  the  endometrium  that  are  difficult  or  impos- 
sible to  eradicate — diseases  like  chronic  gonorrhea,  where 
the  infection  lurks  in  the  distal  ends  of  the  utricular 
glands  and  defies  our  methods  of  treatment.  Operators 
have  repeatedly  removed  a  unilateral  pyosalpinx,  leaving 
the  second  tube  apparently  perfectly  healthy,  and  yet, 
after  the  lapse  of  a  few  months,  a  second  operation  has 
been  necessary  for  the  relief  of  a  similar  pyosalpinx  on 
the  other  side. 

Symptoms  of  Acute  and  Chronic  Salpingitis. — The 
symptoms  of  acute  salpingitis  are  usually  obscured  by 
the  accompanying  symptoms  of  endometritis,  ovarian 
congestion  and  inflammation,  and  localized  peritonitis. 
The  woman  complains  of  pelvic  pain  and  tenderness, 
which  are  most  severe  in  one  or  both  ovarian  regions. 
There  are  elevation  of  temperature  and  rapid  pulse.  The 
knees  are  often  drawn  up  as  in  peritonitis. 

Bimanual  examination  reveals  marked  tenderness  upon 
pressure  in  the  vaginal  fornices.  There  is  an  indistinct 
sense  of  fulness  in  the  region  of  the  tubes.     If  the  pelvic 


288      A    TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

peritoneum  and  cellular  tissue  are  involved,  the  whole 
vaginal  vault  vs^ill  feel  full  and  resistant.  The  tissues 
lying  to  the  sides  and  behind  the  uterus  are  thickened 
and  resistant.  If  the  woman  is  thin  and  there  is  not 
much  surrounding  inflammation,  it  is  sometimes  possible 
to  palpate  the  enlarged  tender  tube  between  the  vaginal 
finger  and  the  abdominal  hand.  Usually,  however,  the 
tenderness  is  too  great  to  permit  this.  The  tube,  from 
its  increase  in  weight,  may  fall  below  its  normal  level, 
and  may  be  felt  lying  behind  the  uterus  in  Douglas's 
pouch. 

Usually,  in  cases  of  acute  salpingitis,  the  examiner  is 
obliged  to  content  himself  with  the  determination  of  an 
indistinct  fulness  and  marked  tenderness  in  the  region  of 
the  Fallopian  tubes. 

Before  the  true  pathology  of  salpingitis  was  known 
these  cases  were  described  as  pelvic  peritonitis  or  pelvic 
cellulitis.  It  was  supposed  that  the  inflammation  in- 
volved the  peritoneum  of  the  pelvis  or  the  cellular  tissue 
of  the  broad  ligaments.  It  is  true  that  this  is  often  the 
case,  and  that  inflammation  of  these  structures  accom- 
panies the  salpingitis,  but  it  is  the  tubal  inflammation 
which  is  the  primary  disease. 

The  most  pronounced  symptom  of  chronic  salpingitis 
is  pain.  The  pain  is  referred  to  one  or  to  both  ovarian 
regions  as  the  disease  is  unilateral  or  bilateral.  It  is  due 
not  only  to  the  salpingitis,  but  to  the  accompanying  ova- 
ritis. The  pain  is  continuous.  It  is  relieved  by  the  re- 
cumbent posture,  and  is  increased  whenever  the  woman 
is  upon  her  feet  or  is  performing  any  work.  The  pain 
is  increased  by  a  jolt  or  sudden  movement,  by  defecation, 
often  by  urination  and  by  coitus.  The  pain  during  co- 
itus, from  direct  pressure,  is  often  so  great  that  marital 
relations  are  abolished.  I  have  seen  a  woman  with  sal- 
pingitis who  was  obliged  to  take  a  dose  of  morphine 
before  every  act  of  defecation.  The  pain  from  the  jolt- 
ing of  a  carriage  often  renders  riding  impossible. 

The  pain  is  dull  and  aching  in  character  or  sharp  and 


DISEASES  OF  THE  FALLOPIAN  TUBES.        289 

lancinating.  It  may  extend  down  the  anterior  aspect  of 
the  thighs. 

The  pain  is  very  much  worse  at  each  menstrual  period. 
All  the  genital  structures  become  congested  and  swollen 
at  this  time,  and  such  phenomena,  occurring  in  the  ad- 
herent inflamed  tubes  and  ovaries,  often  cause  unbear- 
able pain.  The  dysmenorrhea  in  salpingitis  is  usually 
very  characteristic.  It  begins  several  days — sometimes  a 
week — before  the  bleeding  appears.  It  starts  in  one  or 
both  ovarian  regions,  and  radiates  thence  throughout  the 
pelvis  and  down  the  thighs.  It  will  be  remembered  that 
the  dysmenorrhea  of  anteflexion  begins  only  a  few  hours 
before  the  bleeding — that  the  pain  is  usually  situated  in 
the  center  of  the  lower  abdomen,  in  the  region  of  the 
uterus,  is  expulsive  in  character,  and  is  relieved  when 
the  bleeding  has  become  well  established. 

The  dysmenorrhea  of  salpingitis  usually  lasts  through- 
out the  whole  of  the  period. 

The  pain  of  salpingitis  persists  throughout  the  whole 
course  of  the  disease.  It  is  common  to  all  forms  of  sal- 
pingitis, and  seems  to  bear  no  relation  to  the  gross  cha- 
racter of  the  lesions  of  the  tubes.  The  pain  and  the 
dysmenorrhea  are  often  as  marked  in  a  case  of  salpingitis 
without  cystic  distention  as  in  a  case  of  large  pyosalpinx. 

The  pain  persists  after  the  dangerous  stages  of  the  dis- 
ease have  been  passed.  Relief  begins  only  with  the 
cessation  of  menstruation,  when  general  atrophy  takes 
place  in  the  genital  organs. 

The  pain  of  salpingitis  is  often  obvious  from  the  ex- 
pression and  the  posture  of  the  woman.  She  walks  with 
the  body  slightly  flexed  forward;  she  sits  down  gently 
upon  a  chair;  she  protects  herself,  by  support  with  the 
hand,  from  the  jolting  of  a  carriage  or  a  car. 

The  woman  frequently  suffers  with  marked  exacerba- 
tions of  the  pain,  which  occur  independently  of  the  men- 
strual periods,  and  are  caused  by  leakage  from  the  tube 
and  the  resulting  local  peritonitis.  The  woman  often 
describes  such  attacks  as  attacks  of  "inflammation  of  the 

19 


290      .-I   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

bowels."  They  occur  usually  during  the  eariy  stages  of 
the  disease.  Each  attack,  if  survived,  results  in  a  more 
perfect  closure  of  the  ostium  abdominale,  aud  diminishes 
the  risk  of  subsequent  attacks.  At  these  times  all  the 
symptoms  of  local  peritonitis  are  present:  elevated  tem- 
perature, rapid  pulse,  local  or  general  distention,  and 
tenderness.  In  any  case  of  pyosalpinx  or  of  old  chronic 
salpingitis  close  questioning  of  the  patient  will  elicit  a 
history  of  this  kind. 

Acute  attacks  of  pain,  fever,  and  other  disturbance 
also  occur  in  cases  of  chronic  salpingitis  from  acute  re- 
infection of  the  diseased  tube.  The  disease  may  have 
been  quiescent  for  a  long  time,  and  yet  active  reinfection 
may  take  place  by  way  of  the  uterine  cavity  or  by  the 
passage  of  the  colon  bacillus  through  an  adherent  intes- 
tinal wall;  or  infection  may  occur  through  an  adherent 
bladder. 

Salpingitis  is  usually  accompanied  by  menorrhagia. 
It  is  impossible  to  determine  how  much  of  this  is  to  be 
attributed  to  the  tubal  disease.  There  is  always  an  ac- 
companying endometritis  which  is  sufficient  to  account 
for  it. 

Sterility  is  the  rule  in  cases  of  salpingitis.  The  disease 
of  the  mucous  membrane  and  the  destruction  of  the  ciliae 
render  the  passage  of  the  ovum  into  the  uterus  difficult. 
For  this  reason  tubal  pregnancy  may  occur  in  salpingitis, 
impregnation  and  attachment  of  the  ovum  taking  place 
within  the  tube.  Inflammation  of  the  ovar\',  which  pre- 
vents the  rupture  of  the  ripened  ovarian  follicles,  is  an- 
other cause  of  the  sterility.  "When  the  abdominal  ostia 
are  closed  absolute  sterility  is  present. 

In  chronic  salpingitis  the  condition  of  the  Fallopian 
tubes  is  revealed  by  bimanual  examination.  The  tube 
usually  falls  below  its  normal  level,  and  may  be  felt  by 
the  vaginal  finger  lying  beside  the  uterus,  or  behind  it, 
in  Douglas's  pouch.  By  careful  palpation  the  connection 
of  the  tubal  tumor  with  the  uterus  may  be  traced.  Bi- 
manual examination  is  most  satisfactory  in  the  quiescent 


DISEASES  OF  THE  FALLOPIAN  TUBES.        291 

Stages  of  the  disease.  During  an  exacerbation  or  during 
one  of  the  acute  attacks  of  inflammation  the  tenderness 
prohibits  thorough  palpation,  and  the  surrounding  inflam- 
matory infiltration  masks  the  condition  of  the  tube.  The 
tube  may  be  felt  as  a  hard  cord,  or  as  a  cystic  tumor  with 
the  ovary  lying  in  its  concavity,  or  as  a  tortuous,  sausage- 
shaped  mass. 

In  old  chronic  cases  the  tube  and  ovary  mav  be  felt  as 
a  hard,  knot-like  mass  adherent  to  the  side  of  the  uterus 
or  coiled  about  the  cornu  (Fig.  151). 

In  nearly  every  case  the  isthmus  is  rendered  hard  and 
cord-like  by  inflammatory  infiltration.  This  indurated 
condition  of  the  isthmus  is  a  feature  of  tubal  disease  that 
is  usually  readily  determined,  and  it  is  of  decided  diag- 
nostic value.  -  The  connection,  by  such  a  cord,  of  the 
mass  felt  in  the  pelvis  with  the  uterine-  cornu  is  the 
most  valuable  proof  that  the  tumor  is  tubal  in  character. 
Diagnosis. — The  diagnosis  of  chronic  disease  of  the 
Fallopian  tubes  must  be  made  from  a  study  of  the  history, 
the  symptoms,  and  by  physical  examination. 

The  history  is  always  of  value.  Careful  questioning 
will  usually  show  that  the  ovarian  pain  dates  from  a 
criminal  abortion,  from  an  attack  of  fever  after  a  miscar- 
riage or  labor,  or  from  a  suspicious  coitus.  Women  who 
have  been  infected  with  chronic  gonorrhea  by  their  hus- 
bands attribute  the  origin  of  the  disease  to  their  mar- 
riage. The  woman  will  often  say  that  for  some  days 
after  marriage  she  suffered  with  irritation  and  burning 
of  the  external  genitals,  with  dysuria,  perhaps  with  a 
slight  vaginal  discharge,  and  that  after  this,  very  gradu- 
ally, the  ovarian  pain  developed.  She  may  have  had  one 
child  or  a  miscarriage,  but  with  this  exception  is  usually 
sterile. 

The  history  of  attacks  of  local  peritonitis,  confining 
the  women  to  bed  for  several  days  or  weeks,  can  also  usu- 
ally be  obtained. 

The  character  and  the  situation  of  the  pain  and  the 
character  of  the  dysmenorrhea  usually  point  strongly  to 


292      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

salpingitis.  The  physical  examination  is  not  by  any 
means  always  satisfactory.  The  small  flaccid  tubal  tu- 
mors are  often  difficult  to  palpate,  especially  in  fat 
women,  and  the  gross  forms  of  the  disease  may  be  ob- 
scured by  surrounding  adhesions  and  inflammation.  The 
examination,  however,  when  taken  in  connection  with 
the  history  and  the  symptoms,  will  usually  enable  one  to 
make  the  diagnosis.  Inflammatory  tumors  in  the  female 
pelvis  are  very  generally  tubal  in  origin. 

It  is  difficult  to  estimate  the  mortality  of  salpingitis. 
It  is  certainly  a  frequent  cause  of  death — not  only  im- 
mediately, by  some  of  the  acute  accidents  that  may  occur, 
but  as  a  result  of  gradual  exhaustion  from  prolonged  sup- 
puration. Acute  salpingitis,  and  the  purulent  forms  of 
the  disease,  should  always  be  viewed  with  anxiety.  As 
appendicitis  is  the  usual  cause  of  peritonitis  in  man,  so  is 
salpingitis  the  usual  cause  of  this  disease  in  the  woman. 
In  every  case  of  peritonitis  in  a  woman,  therefore,  care- 
ful examination  of  the  pelvic  organs  should  be  made. 

Salpingitis  is  an  exceedingly  common  disease.  It  oc- 
curs in  all  classes  of  society,  but  most  frequently  in  the 
lower  walks  of  life.  Salpingitis  is  the  rule  in  prostitutes, 
and  in  them  is  caused  by  gonorrhea  or  by  septic  infection 
at  criminal  abortion. 

Treatment. — The  treatment  of  acute  salpingitis  in  its 
early  stage  should  be  expectant:  absolute  rest  in  the 
recumbent  position,  vaginal  douches  of  a  gallon  of  hot 
sterile  water  (ioo°-iio°  F.)  two  or  three  times  a  day, 
small  doses  of  saline  purgatives  (Rochelle  salts,  3ss-3J 
every  one  or  two  hours)  until  mild  purgation  is  produced, 
should  be  prescribed,  and  should  be  continued  as  re- 
quired. Relief  of  pain  is  afforded  by  hot  fomentations 
over  the  lower  abdomen.  It  is  best  to  administer  no 
opium,  as  it  is  very  important  to  watch  these  cases  closely, 
and  the  symptoms  that  demand  operation  might  be 
masked  by  the  administration  of  an  anodyne.  Examina- 
tions should  be  made  with  great  care  and  gentleness,  and 
no  oftener  than  is  necessary  to  determine  the  progress  of 


DISEASES  OF  THE  FALLOPIAN  TUBES.        293 

the  disease.     If  the  patient  is  progressing  satisfactorily, 
repeated  examinations  are  contraindicated. 

A  chill  followed  by  a  rapid  high  elevation  of  tempera- 
ture (io5°-io6°  F.)  is  often  caused  by  even  gentle  manip- 
ulation of  the  upper  organs  of  generation  in  cases  of 
acute  inflammation. 

The  case  must  be  watched  carefully  and  continuously. 
In  the  gonorrheal  and  septic  forms  of  the  disease  there  is 
great  danger  of  extension  to  the  peritoneum,  or  of  the 
formation  of  a  tubal  or  other  form  of  pelvic  abscess  that 
will  imperil  the  life  of  the  woman. 

As  a  general  rule,  it  may  be  said  that,  unless  there  are 
well-marked  symptoms  of  extensive  pelvic  peritonitis, 
01  unless  a  distinct  tumor  can  be  felt  in  the  pelvis,  ope- 
ration is  not  indicated.  As  resolution  undoubtedly  takes 
place  even  after  severe  acute  attacks  of  salpingitis,  it  is 
right  to  treat  the  woman  with  this  end  in  view  rather 
than  to  resort  to  an  immediate  mutilating  operation. 

If,  under  the  expectant  plan  of  treatment,  the  patient 
does  not  improve;  if  the  area  of  pelvic  tenderness  in- 
creases; if  the  local  tympany  (which  may  at  first  be 
present  only  on  one  or  both  sides  of  the  pelvis,  and 
which  indicates  merely  local  peritoneal  irritation  or  in- 
flammation) extends  upward;  if  the  temperature  and 
pulse-rate  increase;  if  constipation  appears;  if,  in  fact, 
indications  of  extension  of  the  peritonitis  are  present,— 
celiotomy  should  be  immediately  performed.  The  dis- 
eased tube  or  tubes  should  be  removed,  and,  if  necessary, 
the  abdomen  should  be  drained. 

Fatal  peritonitis  sometimes  results  within  three  or  four 
days  after  the  onset  of  acute  salpingitis.  As  soon,  there- 
fore, as  the  physician  realizes  the  imminence  of  this 
complication  in  any  case,  he  should  not  delay  in  remov- 
ing the  source  of  infection. 

The  other  acute  termination  of  salpingitis,  the  forma- 
tion of  an  abscess  in  the  pelvis,  likewise  demands  opera- 
tive interference.  This  condition  is  readily  recognized. 
The  woman  has  one  or  more  chills.     The  temperature 


294     '4   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

becomes  more  elevated  and  the  pulse  more  rapid.  The 
pelvic  tenderness  and  pain  may  become  more  distinctly 
localized  to  one  or  both  ovarian  regions.  Defecation  and 
urination  increase  the  pain.  Bimanual  examination  re- 
veals an  exceedingly  tender  mass,  either  indurated  or 
perhaps  soft  and  fluctuating,  lying  to  either  side  of,  or 
behind  the  uterus.  The  character,  upon  palpation,  of 
the  mass  depends  upon  the  nature  and  extent  of  the  peri- 
toneal adhesions  that  surround  it.  The  diagnosis  of  a 
pelvic  abscess  resulting  from  acute  salpingitis  is  usually 
easy. 

There  is  some  difference  of  opinion  among  operators  in 
regard  to  the  best  treatment  for  this  condition.  Some 
advise  evacuation  of  the  abscess  by  way  of  the  vagina; 
others  advise  celiotomy,  with  removal  of  the  abscess  and 
the  Fallopian  tube  that  caused  it,  followed,  if  necessary, 
by  abdominal  or  vaginal  drainage.  I  prefer  the  latter 
method  of  treatment,  for  reasons  that  will  appear  under 
the  consideration  of  the  technique  of  operation. 

Treatment  of  Chronic  Salpingitis. — Cases  of  simple 
chronic  catarrhal  salpingitis  undoubtedly  recover  after 
the  cure  of  the  endometrial  disease  of  which  the  salpin- 
gitis forms  a  part.  The  tube  may  be  restored  perfectly 
to  its  normal  condition;  or  there  may  remain  an  atrophic 
condition  of  the  mucous  membrane;  or  the  fimbriae  may 
be  left  somewhat  distorted,  crumpled,  or  slightly  drawn 
within  the  tube;  or  there  may  be  a  few  fine  peritoneal 
adhesions,  like  cobwebs,  between  the  distal  end  of  the 
tube,  the  broad  ligament,  and  the  ovary.  Such  slight 
lesions  may  cause  no  trouble  beyond  interfering  a  little 
with  the  fecundity  of  the  woman. 

When,  however,  the  adhesions  are  more  extensive, 
treatment  for  their  relief  may  be  demanded,  even  though 
all  inflammatory  action  has  disappeared  from  the  body  of 
the  uterus  and  the  tubes.  Treatment  in  such  cases  is 
demanded,  not  to  cure  the  salpingitis  or  on  account  of 
any  danger  that  threatens  the  woman's  life,  but  to  relieve 
the  pain  caused  by  the  results  of  the  inflammation. 


DISEASES  OF  THE  FALLOPIAN  TUBES.        295 

It  may  be  necessary  to  perform  celiotomy  in  order  to 
free  or  break  up  adhesions  that  bind  down  the  ovary  in 
an  abnormal  position,  or  to  liberate  an  adherent  intestine, 
or  to  replace  a  uterus  that  has  been  displaced  by  the  trac- 
tion of  adhesions. 

The  degree  of  suffering  experienced  by  the  woman  is 
the  guide  in  advising  such  operative  interference. 

The  treatment  by  pelvic  massage  for  the  relief  of  pelvic 
adhesions  of  this  kind  is  now  upon  trial.  It  seems  to  do 
good  in  some  cases.  Much  judgment  is  required  in  the 
selection  of  cases  to  which  massage  may  be  applied. 

In  discussing  the  treatment  of  chronic  salpingitis  the 
cases  may  be  divided  into  two  classes:  those  in  which 
palliative  treatment  may  be  followed,  and  those  in  which 
operation  is  demanded. 

There  are  a  great  number  of  cases  of  chronic  salpin- 
gitis in  which  there  is  no  gross  disease  of  the  tubes,  and 
in  which  operation  upon  the  tubes  is  not  immediately 
indicated.  It  is  proper  in  such  cases  to  try  milder  pallia- 
tive treatment  first. 

Salpingitis  is  ahvays  preceded,  and  usually  accom- 
panied, by  inflammation  of  the  endometrium,  and  in 
every  chronic  case  attention  should  first  be  directed  to 
the  cure  of  the  endometritis. 

If  there  is  no  tubal  and  ovarian  displacement — that 
is,  if  the  ovary  is  not  prolapsed;  if  the  uterus  has  not 
been  retroverted;  if  there  are  no  extensive  tubal  adhe- 
sions; and  if  there  is  no  gross  disease  of  the  tube,  such 
as  pyosalpinx,  hydrosalpinx,  hematosalpinx,  a  thorough 
curetting  of  the  uterus,  or,  if  necessary,  a  trachelorrhaphy 
or  an  amputation  of  the  cervix,  will  often  relieve  the 
woman  of  her  suffering,  and  it  may  not  be  necessary  to 
operate  for  the  damaged  tubes. 

In  all  such  cases,  however,  the  operator  must  be  very 
careful  to  exclude  active  or  purulent  tubal  disease.  If  he 
overlooks  a  pyosalpinx,  the  curettage  or  the  trachelor- 
rhaphy may  be  followed  by  an  active  peritoneal  inflam- 
mation that  will  destrov  the  woman. 


296     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

If  there  is  ovarian  or  uterine  displacement,  we  cannot 
expect  relief  until  these  conditions  have  been  treated,  and 
such  treatment  usually  requires  celiotomy. 

The  pain  and  dysmenorrhea  of  chronic  tubal  disease 
may  be  relieved  by  rest  in  the  recumbent  position  during 
the  menstrual  period;  by  the  administration  of  saline 
laxatives  (the  pain  is  always  increased  by  constipation); 
by  vaginal  douches  of  large  quantities  of  hot  water  (one 
gallon  at  110°  F.)  administered  two  or  three  times  a  day 
in  the  recumbent  posture;  and  by  applications  of  Church- 
ill's tincture  of  iodine  to  the  vaginal  vault,  and  the  use 
of  the  glycerin  tampon.  The  directions  for  this  treat- 
ment have  been  given  under  the  preparatory  treatment 
of  laceration  of  the  cervix. 

Such  treatment  is  only  palliative:  it  relieves  the  pain, 
but  it  will  not  cure  well-established  chronic  salpingitis. 

In  many  cases  the  woman  experiences  little,  if  any, 
relief  from  this  treatment.  In  other  cases,  though  the 
pain  may  be  very  much  relieved  while  she  is  taking  treat- 
ment, yet  it  returns  as  soon  as  the  treatment  is  stopped, 
and  she  becomes  unwilling  to  lead  the  life  of  an  invalid 
under  constant  medical  care,  with  but  little  prospect  of 
relief  until  the  menopause  is  reached.  It  is  then  neces- 
sary to  consider  operation. 

The  second  class  of  cases  referred  to — those  in  which 
immediate  operation  is  demanded,  and  in  which  it  is 
dangerous  to  delay  and  useless  to  try  the  palliative  treat- 
ment— includes  a  great  variety.  Such  cases  are — the 
gross  forms  of  tubal  disease,  hydrosalpinx,  hematosal- 
pinx, and  pyosalpinx;  salpingitis  with  prolapsed  and  ad- 
herent tube  and  ovary;  salpingitis  with  retrodisplace- 
ment  of  the  uterus;  all  the  milder  forms  of  salpingitis 
which  have  resisted  palliative  treatment. 

The  operative  treatment  of  salpingitis  usually  demands 
celiotomy.  Some  operators,  however,  prefer  to  reach  the 
uterine  appendages  by  way  of  the  vagina. 

The  details  of  the  operative  technique  of  salpingo- 
oophorectomy  will  be  given  in  a  subsequent  chapter.    As 


•      DISEASES  OF  THE  FALLOPIAN  TUBES.         297 

a  rule,  the  operation  of  celiotomy  for  salpingitis  should 
always  be  immediately  preceded  by  thorough  curetting 
of  the  uterus  and,  if  necessary,  by  trachelorrhaphy  or 
an  amputation  of  the  cervix. 

After  the  abdomen  has  been  opened  the  operation  con- 
sists in  freeing  adhesions,  rendering  patulous  the  abdom- 
inal ostium  of  the  tube,  replacing  the  uterus,  and,  if 
necessary,  removing  the  tube  and  ovary  on  one  or  on 
both  sides. 

Removal  of  the  tubes  and  ovaries — salpingo-oophorec- 
tomy — is  usually  necessary.  In  pyosalpinx  this  operation 
should  always  be  performed.  If  the  woman  is  young  and 
is  very  anxious  to  have  children,  every  attempt  should  be 
made  to  save,  at  any  rate,  one  tube  and  ovary.  Remark- 
able cases  of  conception  have  occurred  after  conservative 
operations  upon  badly  diseased  tubes. 

The  adhesions  about  the  abdominal  ostium  may  be 
broken  and  the  imprisoned  fimbriae  freed;  or  if  the  os- 
tium is  firmly  closed,  an  incision  may  be  made  in  the 
wall  of  the  tube,  the  peritoneum  stitched  to  the  mucous 
coat,  and  a  new  ostium  produced.  In  one  case  concep- 
tion followed  such  an  operation  in  which  the  ovary  was 
sutured  in  the  artificial  opening  made  in  the  tube.  Con- 
ception has  occurred  after  both  tubes  had  been  amputated 
at  the  uterine  cornua. 

In  all  such  conservative  operations,  however,  the 
woman  should  be  told  of  the  probability  of  failure  and 
the  probable  necessity  for  a  subsequent  radical  operation. 
The  successful  cases  show  the  possibilities  of  surgery, 
but,  unfortunately,  they  are  exceptional.  Sterility  usu- 
ally continues,  the  pain  is  usually  imrelieved,  and  a  sec- 
ond radical  operation  becomes  necessary. 

Such  conservative  operations  upon  badly  diseased 
tubes  should  be  performed,  therefore,  only  when  the 
woman  is  young  and  anxious  for  children.  Whenever 
the  abdominal  ostium  is  closed  and  the  ovary  is  adherent, 
it  is  safest  to  perform  a  complete  salpingo-oophorectomy. 
This  is  always  indicated  when  the  woman  is  near  the 


298      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

menopause  or  when  immediate  certain  relief  is  demanded 
from  prolonged  suffering. 

In  some  cases  the  question  arises  as  to  whether  both 
tubes  should  be  removed  when  only  one  is  grossly  dis- 
eased. In  the  early  stages  of  chronic  pyosalpinx  it  often 
happens  that  but  one  tube  is  found  diseased,  while  the 
other  is  apparently  perfectly  healthy  or  is  only  slightly 
adherent.  Experience  has  shown  that  in  a  great  many 
cases  of  tubal  disease  in  which  only  one  tube  was  re- 
moved, the  second  tube  has  become  similarly  affected, 
often  within  a  short  time,  and  a  second  operation  has 
been  required.  This  disaster  is  not  likely  to  occur  if  the 
endometrial  disease  is  eradicated  by  thorough  curetting 
at  the  time  of  the  first  operation.  But  in  some  forms  of 
salpingitis,  as  the  gonorrheal,  the  infection  is  so  deeply 
seated  in  the  distal  ends  of  the  utricular  glands  that  the 
most  vigorous  curetting  fails  to  remove  it,  and  the  sec- 
ond tube  will  become  infected  from  the  original  focus  in 
the  uterus. 

So  common  is  such  occurrence  that  many  women, 
profiting  by  the  experience  of  their  friends,  request  the 
operator  to  remove  both  tubes,  even  though  he  finds  but 
one  diseased.  The  advice  already  given  in  regard  to  con- 
servative operation  applies  here  also.  It  is  safest  in  all 
forms  of  pyosalpinx  to  remove  both  appendages.  In  the 
less  serious  forms  of  salpingitis — hydrosalpinx  and  ad- 
herent tubes  without  cystic  distention — there  is  less  dan- 
ger of  recurrence,  and  the  unilateral  operation  may  be 
more  safely  performed.  The  importance  of  thorough 
treatment  of  the  endometritis  at  the  same  time  is  empha- 
sized by  these  considerations. 

In  many  cases  in  which  double  salpingo-oophorectomy 
is  performed  it  is  often  advisable  to  remove  the  uterus  at 
the  same  time.  The  uterus  may  be  amputated  at  any 
convenient  point  of  the  cervix,  or  it  may  be  completely 
removed  at  the  vaginal  junction.  This  operation  ensures 
more  certain  and  speedy  relief  from  suffering,  and  is 
attended  by  but  little,  if  any,  greater  mortality  than  the 


DISEASES  OF  THE  FALLOPIAN  TUBES.        299 

simple  salpingo-oophorectomy.  The  uterus  without  the 
tubes  and  ovaries  is  a  useless  structure.  The  operation 
is  advisable  if  the  uterus  is  retroverted  and  adherent, 
when  the  uterus  is  large  and  subinvoluted,  when  the  dis- 
ease of  the  endometrium  is  severe  and  is  likely  to  persist 
— in  any  case,  in  fact,  in  which  the  physician  fears  that 
the  uterus  may  be  a  subsequent  source  of  trouble. 

SUPPURATION  OF  THE  PELVIC  CELLULAR  TISSUE. 

Pus  in  the  female  pelvis,  to  which  condition  the  vague 
term  of  pelvic  abscess  has  been  applied,  is  usually  the 
result  of  salpingitis  producing  a  pyosalpinx,  of  ovarian 
abscess,  or  of  suppuration  of  an  ovarian  cyst,  very  often 
a  dermoid.  The  disease  may  also  occur  from  infection 
of  a  broad-ligament  hematoma  or  from  a  pelvic  hemato- 
cele caused  by  a  ruptured  tubal  pregnancy. 

Following  these  conditions  the  cellular  tissue  of  the 
pelvis  may  become  affected,  so  that  the  purulent  accu- 
mulation may  make  its  way  between  the  layers  of  the 
broad  ligament  or  in  some  other  part  of  the  pelvis. 

Before  the  days  of  modern  abdominal  surgery  these 
accumulations  of  pus  were  evacuated  through  the  vagina, 
the  rectum,  or  the  abdominal  wall,  according  to  the  direc- 
tion in  which  the  abscess  seemed  to  point  or  in  which  it 
seemed  to  be  most  accessible.  The  sinuses  thus  formed 
often  persisted  for  years  or  during  the  remaining  life  of 
the  woman.  There  were  many  theories  in  regard  to  the 
origin  of  the  suppuration,  it  being  impossible  to  deter- 
mine its  true  nature  without  opening  the  abdomen. 
Now  we  know  that  the  great  majority  of  such  pelvic 
abscesses  originated  in  septic  infection  of  the  Fallopian 
tubes,  and  that  infection  of  the  pelvic  cellular  tissue 
was  secondary. 

There  are,  however,  rare  cases  in  which  the  suppura- 
tion occurs  primarily  in  the  cellular  tissue  of  the  pelvis, 
without  any  involvement  whatever  of  the  tubes  or 
ovaries.  Such  an  accumulation  of  pus  is  usually  found 
in  the  cellular  tissue  of  the  broad  ligaments;  it  some- 


300      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

times  occurs  in  the  utero- vesical  tissue,  and  rarely  in  the 
tissue  back  of  the  cervical  neck. 

The  cause  of  such  suppuration  is  usually  infection,  by 
way  of  the  lymphatics,  from  the  uterus,  or  by  the  pas- 
sage of  septic  organisms  directly  through  the  uterine  wall. 
The  condition  is  most  frequently  the  result  of  puerperal 
sepsis.  I  have  on  one  occasion  seen  it  occur  in  connec- 
tion with  extensive  venereal  ulceration  of  the  external 
genitals.  It  seems  probable  that  a  pelvic  lymphatic 
gland,  becoming  infected,  may  break  down  and  sup- 
purate, forming  the  starting-point  of  the  abscess. 

The  symptoms  of  this  form  of  pelvic  abscess  are  those 
characteristic  of  any  other  kind  of  suppuration  in  the 
pelvis. 

The  purulent  accumulation  may  be  detected  by  bi- 
manual examination.  It  usually  bulges  into  the  vagina 
at  the  lateral  fornices  or  before  or  behind  the  cervix. 
The  abscess-mass  is  in  close  relationship  with  the  uterus. 
In  this  respect  it  differs  from  a  simple  tubal  or  an  ovarian 
abscess,  in  which  cases  a  distinct  separation  of  the  tubal 
or  ovarian  tumor  from  the  uterus  may  be  determined,  at 
any  rate,  before  the  pelvic  cellular  tissue  has  become  in- 
volved. 

If  the  abscess  bulge  in  the  anterior  vaginal  fornix,  it 
is  very  probably  of  neither  tubal  nor  ovarian  origin,  as 
tubal  and  ovarian  abscesses  lie  to  the  side  of,  or  behind, 
the.  uterus. 

The  sense  of  fluctuation  is  often  difficult  or  impossible 
to  determine.  The  infiltration  of  the  surrounding  struc- 
tures gives  to  the  mass  a  dense  hard  feeling  that  obscures 
fluctuation.  To  the  experienced  finger,  however,  this 
indurated  condition  of  the  tissues  is  characteristic  of 
pelvic  suppuration,  as  is  the  sense  of  fluctuation  else- 
where. 

The  treatment  of  pelvic  suppuration  of  this  nature  is 
evacuation  by  way  of  the  vagina.  The  incision  should 
be  made  into  the  most  prominent  part  of  the  mass. 
When  made  into  the  lateral  fornices,  the  operator  should 


DISEASES  OF  THE  FALLOPIAN  TUBES.         301 

remember  the  position  of  the  ureters  and  the  uterine 
arteries.  The  ureters  lie  a  little  over  half  an  inch  from 
the  cervix.  In  every  case  it  is  safest  to  make  the  incision 
close  to  the  cervix  and  to  work  carefully  into  the  abscess- 
cavity.  The  pus  should  be  evacuated,  and  a  double  drain- 
age-tube should  be  introduced  for  subsequent  washing. 

In  most  cases,  however,  the  physician  cannot  deter- 
mine with  any  certainty  that  the  abscess  is  simply  con- 
fined to  the  pelvic  cellular  tissue  and  did  not  originate  in 
the  Fallopian  tube.  If  there  is  any  doubt  of  this  kind, 
celiotomy  should  be  performed  and  the  true  nature  of  the 
condition  determined.  If"  a  pyosalpinx  or  an  ovarian 
abscess  is  present,  as  is  usually  the  case,  the  condition 
may  be  dealt  with  as  has  already  been  advised.  If  the  ute- 
rine adnexa  are  healthy,  the  abdomen  may  be  closed  and 
a  subsequent  vaginal  incision  may  be  made. 

Indiscriminate  evacuation  of  collections  of  pus  in  the 
pelvis  by  way  of  the  vagina  has  resulted  in  a  great  deal 
of  harm.  The  abscess,  being  usually  of  tubal  origin, 
often  persists  indefinitely.  Intestine,  ureters,  bladder, 
and  blood-vessels  have  often  been  injured;  and  when  sub- 
sequent celiotomy  is  performed  the  operation  is  attended 
with  great  danger  from  the  presence  of  the  fistulous 
opening. 


CHAPTER   XXV. 
DISEASES  OF  THE   FALLOPIAN  TUBES    (Continued). 

TUBERCULOSIS. 

Tuberculosis  attacks  the  Fallopian  tubes  much  more 
frequently  than  any  other  part  of  the  genital  apparatus. 
The  disease  may  be  associated  with  tuberculosis  of  the 
peritoneum  or  with  tuberculosis  of  the  ovaries  and  the 
uterus.  As  has  already  been  said,  tuberculosis  of  the 
uterus  often  originates  in  the  tubes  and  extends  thence  to 
the  endometrium. 

The  tubercular  Fallopian  tube  varies  much  in  appear- 
ance according  to  the  nature  and  stage  of  the  disease. 
The  strictly  tubercular  lesions  may  be  masked  by  those 
of  ordinary  inflammation.  There  may  be  peritoneal  ad- 
hesions, often  very  dense  and  widespread,  between  the 
tube  and  adjacent  organs,  and  the  ostium  abdominale 
may  be  closed,  as  in  non-tubercular  salpingitis. 

In  some  cases  these  simple  inflammatory  adhesions 
probably  existed  before  the  tubercular  infection  took 
place,  the  tuberculosis  occurring  in  an  old  diseased  tube. 
In  other  cases  it  is  probable  that  the  inflammatory  ad- 
hesions and  products  occurred  as  a  result  of  the  tuber- 
culosis, which  attacked  a  tube  previously  healthy.  In 
the  latter  case  such  adhesions  may  be  viewed  as  a  conser- 
vative process. 

The  tubercular  tube  is  often  very  much  enlarged  from 
infiltration  of  its  walls  and  dilatation  of  its  lumen.  It 
may  be  filled  with  typical  caseous  material,  and  when 
this  is  removed  the  mucous  membrane  will  be  found  the 
seat  of  deep,  jagged,  ulcerated  areas. 

If  the  abdominal  ostium  is  not  entirely  closed,  the 
cheesy  material  may  project  into  the  abdominal  cavity. 

302 


DISEASES  OF  THE  FALLOPIAN  TUBES.       303 

If  the  disease  has  extended  to  the  peritoneal  coat,  the 
covering  of  the  tube  will  be  found  studded  with  typical 
tubercles  (Fig.  152).  Such  tuberculosis  of  the  perito- 
neum may  be  confined  to  that  covering  the  tube,  or  it 
may  extend  to  the  uterus  and  throughout  the  abdominal 
cavity. 

In  peritoneal  tuberculosis  that  has  originated  in  the 
tube  the  lesions  are  found  to  be  most  widespread  in  the 
pelvic  peritoneum. 

In  some  cases  the  ostium  becomes  closed,  and  the  tubes 


Fig.  152. 


-Tuberculosis  of  the  Fallopian  tubes.     The  disease  has  extended  to 
the  peritoneum,  which  is  covered  with  tubercles. 


are  found  distended  with  pus,  forming  tubercular  pyo- 
salpinx.  Such  tubes  sometimes  attain  enormous  size, 
containing  a  quart  or  more  of  purulent  material. 

In  less  extreme  cases  than  those  just  described  the  tu- 
bercular area  may  be  limited  to  a  portion  of  the  tube, 
and  gives  rise  to  one  or  more  nodular  enlargements  (Fig. 
153).  In  other  cases  there  is  no  gross  change  in  the  shape 
or  size  of  the  tube,  and  only  a  few  miliary  tubercles  are 
found  scattered  throughout  the  mucous  membrane. 

In  a  very  large  number  of  the  cases  of  tuberculosis  of 
the  Fallopian  tubes,  the  lesions  resemble  in  all  respects 
those  of  ordinary  salpingitis,  and  are  not  in  any  way  rec- 
ognizable by  the  naked  eye  as  characteristic  of  tuber- 


304      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

culosis.  There  are  no  cheesy  contents;  there  are  no  tu- 
bercles upon  the  peritoneum;  the  mucous  membrane 
shows  no  macroscopical  changes  that  would  lead  to  the 
suspicion  of  tuberculosis.  In  these  cases  the  tubes  are 
usually  closed  at  the  abdominal  ostium;  there  may  or 
may  not  be  cystic  distention;  and  the  adhesions,  which 
are  usually  very  firm,  distort  the  shape  of  the  tube  and 
bind  it  to  the  posterior  aspect  of  the  broad  ligament,  the 
uterus,  or  other  pelvic  structure.    Until  very  recent  years 


Fig.  153. — Tuberculosis  of  the  Fallopian  tubes:  A,  ftibercular  nodules. 


such  cases  were  supposed  to  be  simple  cases  of  salpin- 
gitis. Careful  microscopic  examination,  however,  has 
shown  that  this  forms  one  variety  of  tubal  tuberculosis, 
and  that  a  certain  proportion  of  such  cases  of  salpingitis 
are  tubercular.  The  term  ' '  unsuspected  tuberculosis ' ' 
has  been  applied  by  Williams  to  such  cases. 

Cases  of  tuberculosis  of  the  Fallopian  tubes  may  be 
divided  into  three  classes:  Miliary  tuberculosis;  chronic 
diffuse  tuberculosis  (cheesy  tubes);  and  chronic  fibroid 
tuberculosis. 

Miliary  tuberculosis  of  the  tubes  may  be  a  part  of  a 
general  miliary  tuberculosis,  or  it  may  occur  primarily 
in  the  tube.  Microscopic  examination  shows  giant  epi- 
thelioid cell-tubercles  scattered  throughout  the  mucous 
membrane. 


DISEASES  OF  THE  FALLOPIAN  TUBES.        305 

Miliary  tuberculosis  is  the  first  stage  of  tuberculosis  of 
the  tubes.  The  process  may  progress  no  farther,  or  it 
may  become  converted  into  one  of   the  other  varieties. 

In  chronic  diffuse  tuberculosis  the  mucous  membrane  is 
infiltrated  with  epithelioid  cells,  miliary  tubercles,  and 
areas  of  caseation.  The  tube  may  be  filled  with  cheesy 
material  or  with  pus,  and  in  time  the  mucous  membrane 
becomes  completely  destroyed.  In  this  form  of  tubercu- 
losis the  gross  appearances  are  usually  characteristic,  and 
are  those  which  have  already  been  described. 

In  chronic  fibroid  tuberculosis  there  is  a  great  increase 
of  connective  tissue  between  the  tubercles.  The  lumen 
of  the  tube  is  distorted,  and  a  few  miliary  tubercles  are 
found  scattered  through  the  mucous  membrane.  This 
form  of  the  disease  is  very  slow  and  chronic,  and  repre- 
sents a  usual  method  of  spontaneous  cure. 

Since  the  discovery  of  so-called  unsuspected  tuber- 
culosis of  the  Fallopian  tubes  the  disease  has  been  found 
to  be  much  more  frequent  than  was  formerly  supposed. 

Williams  found  tuberculosis  of  the  tubes  in  one  out  of 
every  twelve  operations  for  the  removal  of  tubes  and 
ovaries  that  were  the  seat  of  past  or  present  inflammatory 
disease. 

During  the  past  three  years  Dr.  Beyea  and  I  have  found 
tuberculosis  of  the  tubes  present  in  18  per  cent,  of  the 
cases  that  were  subjected  to  the  operation  of  salpingo- 
oophorectomy  for  inflammatory  disease  of  the  tubes. 

It  may  be  said,  therefore,  that  tuberculosis  is  present 
in  from  8  to  18  per  cent,  of  all  cases  of  inflammatory 
disease  of  the  uterine  appendages.  It  is  impossible, 
however,  to  say  whether  or  not  tuberculosis  is  the  cause 
of  the  disease  in  all  cases,  or  whether  tuberculosis  has 
been  grafted  upon  a  previous  non-tubercular  afiection. 
Other  organisms,  along  with  the  tubercle  bacillus,  are 
frequently  found  in  the  Fallopian  tube. 

Tuberculosis  of  the  Fallopian  tubes  may  be  primary 
or  secondary. 

In  primary  tuberculosis  the  tubes  are  the  primary  seat 
20 


3o6      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

of  the  disease,  being  aflfected  before  other  structures  of 
the  body. 

In  secondary  tuberculosis  the  tubes  are  aflfected  from  a 
tubercular  focus  in  some  other  part  of  the  body. 

Tuberculosis  of  the  tubes  is  usually  secondary. 

Infection  takes  place  in  a  variety  of  ways.  Infection 
through  the  blood  is  the  most  usual  way. 

Infection  may  take  place  from  a  tubercular  ulcer  of  the 
intestine  or  bladder  becoming  adherent  to  the  tube.  The 
tube  may  become  involved  by  extension  of  tuberculosis 
of  the  peritoneum  to  it.  In  many  cases  the  reverse  order 
happens:  the  tube  is  first  involved  by  the  tuberculosis, 
and  the  disease  extends  thence  to  the  peritoneum.  In 
other  cases  it  is  the  peritoneum  that  is  primarily  affected. 
It  seems  probable  that  tubercle  bacilli,  having  gained 
entrance  to  the  peritoneum  from  a  tuberculous  mesen- 
teric gland  or  from  an  intestinal  ulceration,  fall  to  the 
pelvis  and  are  drawn  into  the  Fallopian  tubes,  there 
producing  tuberculous  lesions  without  first  affecting  the 
peritoneum. 

It  seems  probable  that  in  a  good  many  cases  of  tuber- 
culosis of  the  tubes  the  infection  takes  place  from  with- 
out by  way  of  the  genital  tract.  Dirty  instruments, 
syringes,  or  the  examining  finger  may  cause  it  in  this 
way.  Infection  may  also  occur  from  clothing  or  bed- 
sheets  soiled  by  sputum  or  other  tubercular  discharge. 
Coitus  with  men  aflfected  with  genito-urinary  tuberculosis 
or  any  other  form  of  tuberculosis  may  be  an  occasional 
cause.  It  has  been  shown  that  tubercle  bacilli  may  be 
present  in  the  testes  and  prostate  glands  of  consumptives 
without  any  evidence  of  genito-urinary  tuberculosis  being 
present. 

Tubal  tuberculosis  may  occur  by  way  of  the  genital 
tract  from  infection  from  the  discharges  from  some  other 
tubercular  focus  in  the  woman,  as  in  the  lungs,  bladder, 
or  intestinal  tract. 

The  symptoms  of  tuberculosis  of  the  Fallopian  tubes 
are  not  at  all  characteristic.     Most  cases  of  tubal  tuber- 


DISEASES  OF  THE  FALLOPIAN  TUBES.        307 

culosis  have  been  discovered  at  the  autopsy  or  have  been 
unexpectedly  found  at  operation. 

The  symptoms  resemble  those  of  non-tubercular  sal- 
pingitis. There  is  the  same  ovarian  pain  and  dysmenor- 
rhea. Bimanual  examination  reveals  the  enlarged  or 
nodular  and  distorted  condition  of  the  tube.  The  adhe- 
sions are  often  very  firm  and  dense,  and  the  tubal  tumor 
is  often  of  stony  hardness. 

The  diagnosis  of  uncomplicated  tubal  tuberculosis  is 
difficult,  and  in  many  cases  impossible.  If  the  peritoneal 
covering  of  the  tube  is  involved,  the  small  tubercles  may 
sometimes  be  felt  by  vaginal  or  rectal  palpation.  Or,  if 
the  condition  has  extended  to  the  posterior  aspect  of  the 
uterus,  the  tubercles  may  be  felt  here,  by  dragging  the 
cervix  down  with  a  tenaculum  and  palpating  the  poste- 
rior uterine  surface  with  a  finger  in  the  vagina  or  the 
rectum.  The  association  of  salpingitis  with  pulmonary 
tuberculosis  would  lead  the  physician  to  suspect  that  the 
salpingitis  might  be  tubercular.  If  the  woman  has  tuber- 
culosis of  the  peritoneum,  and  the  tubes  are  found  en- 
larged, it  is  most  probable  that  they  are  tubercular.  A 
knowledge  of  a  genito-urinary  lesion  of  tubercular  nature 
in  the  husband  should  lead  us  to  fear  tubal  tuberculosis 
in  the  wife. 

Prognosis. — Tubal  tuberculosis  is  a  dangerous  disease. 
There  are  several  methods  of  termination.  It  very  often 
leads  to  tuberculosis  of  the  peritoneum.  For  this  reason 
peritoneal  tuberculosis  is  more  common  in  women  than 
in  men. 

A  tubercular  abscess  may  be  formed  in  the  pelvis,  and 
the  woman  may  die  as  the  result  of  prolonged  discharge 
and  suppuration,  as  in  the  case  of  non-tubercular  pyo- 
salpinx.  General  tubercular  infection  may  arise  from 
the  tubercular  focus  in  the  tubes. 

Tuberculosis  of  the  tubes  may,  and  probably  often 
does,  undergo  spontaneous  cure.  The  fibroid  changes 
that  have  been  described  lead  to  this  end.  In  some  cases 
calcification  occurs,  as  in  tuberculosis  elsewhere,  and  the 


3o8      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

disease  is  cured  in  this  way.  Fig.  154  represents  an  old 
tubercular  pyosalpinx  that  was  filled  with  calcified  plates. 

Even  though  these  conservative  changes  take  place  and 
all  danger  from  the  tuberculosis  has  disappeared,  the 
woman  will  continue  to  suffer  pain  and  dysmenorrhea 
from  the  tubal  and  ovarian  adhesions. 

Treatment. — The  treatment  of  tubal  tuberculosis  is 
celiotomy,  with  removal  of  the  tubes  and  ovaries.  If 
the  uterus  is  involved,  it  should  also  be  removed.  Re- 
moval of  the  tubes,  however,  is  the  important  feature  of 
the  operation.  I  have  seen  perfect  and  permanent  re- 
covery occur  after  removing  the  tubes,  even  though  the 


Fig.  154. — A  tubercular  pyosalpinx.     To  the  left  are  three  calcified  plates  that 
were  found  in  the  tube. 

disease  had  extended  into  the  uterine  cornua.  As  the  dis- 
ease very  rarely  extends  below  the  internal  os,  the  uterus 
may  be  amputated  at  any  convenient  point  of  the  cervix. 
Tuberculosis  of  the  peritoneum  is  an  indication  for, 
rather  than  a  contraindication  to,  the  operation.  The 
most  extensive  cases  of  peritoneal  tuberculosis  have  been 
cured  by  opening  and  draining  the  abdomen.  If  the 
tubes  are  rendered  inaccessible  from  the  involvement  of 
surrounding  structures,  the  operator  must  content  him- 
self with  opening  and  draining  the  abdomen. 


DISEASES  OF  THE  FALLOPIAN  TUBES.        309 

Adenoma  of  the  Fallopian  tube  is  a  rare  disease;  but 
a  few  cases  have  been  described  in  medical  records.  The 
presence  of  primary  adenoma  in  the  Fallopian  tube  is 
strong  proof  of  the  glandular  character  of  the  mucous 
membrane — an  anatomical  point  which,  as  has  already 
been  said,  has  been  denied  by  some  writers.  In  adenoma 
the  tube  becomes  distended  with  the  typical  adenomatous 
mass,  which  may  protrude  from  the  abdominal  ostium. 

In  some  of  the  reported  cases  there  has  been  found  a 
considerable  quantity  of  free  fluid  in  the  peritoneum, 
though  the  peritoneum  itself  was  not  diseased.  It  seems 
probable  that  this  secretion  originated  in  the  tube  and 
escaped  at  the  ostium. 

Myoma. — Notwithstanding  the  frequency  of  myoma- 
tous tumors  of  the  uterus,  the  condition  is  exceedingly 
rare  in  the  Fallopian  tubes.  The  tumors  originate  in  the 
muscular  coat,  and  are  usually  so  small  as  to  create  no 
disturbance. 

Cancer. — Primary  cancer  of  the  Fallopian  tubes  is  an 
extremely  rare  disease.  A  very  few  isolated  cases  have 
been  reported. 

Cancer  of  the  tubes  secondary  to  cancer  of  the  body 
of  the  uterus  occurs  more  frequently. 

Actinomycosis  of  the  Fallopian  tubes  has  been  de- 
scribed. 

Syphilitic  gummata  occasionally  attack  the  Fallo- 
pian tube  in  women  who  are  the  victims  of  constitu- 
tional syphilis. 

The  diagnosis  of  these  unusual  lesions  of  the  Fallopian 
tubes  is  impossible  with  our  present  knowledge.  The 
conditions  have  usually  been  found  post-mortem  or  have 
been  unexpectedly  discovered  at  operation.  The  subjec- 
tive symptoms  throw  no  light  upon  the  subject  of  differ- 
ential diagnosis.  Examination  reveals  merely  a  tubal 
tumor. 

As  the  rule  is  to  operate  in  all  cases  of  tubal  tumor, 
the  proper  treatment  will  probably  be  applied,  notwith- 
standing the  uncertainty  or  mistake  of  diagnosis. 


CHAPTER   XXVI. 
TUBAL    PREGNANCY. 

Tubal  pregnancy  occurs  when  a  fecundated  ovum  is 
developed  in  the  Fallopian  tube. 

Fecundation  may  take  place  in  the  Fallopian  tube,  be- 
cause spermatozoa  may  pass  through  the  uterus  and  the 
tube  into  the  pelvic  cavity;  but  unless  something  occurs 
to  arrest  the  passage  of  the  fertilized  ovum  into  the 
uterus,  a  normal  uterine  pregnancy  will  result.  It  is  said 
by  Webster  that  predisposition  to  tubal  pregnancy  is  due 
to  a  "developmental  fault,  whereby  there  is  reversion, 
either  of  structure  or  reaction  tendency,  in  the  tubal 
mucosa  to  an  earlier  type  in  mammalian  evolution." 

In  other  words,  decidual  changes,  following  the  fertil- 
ization of  the  ovum,  may  in  some  women  occur  in  the 
mucous  membrane  of  the  Fallopian  tubes  as  well  ^s  in 
that  of  the  uterus.  If  this  condition  is  present  in  any 
case,  and  at  the  same  time  something  occurs  to  impede 
the  passage  of  the  ovum  into  the  uterus,  a  tubal  preg- 
nancy may  take  place. 

Interference  with  the  passage  of  the  ovum  along  the 
tube  has  been  attributed  to  a  variety  of  causes.  Chronic 
salpingitis  is  a  frequent  cause.  It  destroys  the  cilia  of 
the  epithelial  cells  of  the  tubal  mucosa.  It  produces 
thickening  of  the  tubal  walls,  and  causes  peritoneal 
adhesions  that  impede  the  normal  peristaltic  action  of 
the  tube. 

Obstruction  to  the  passage  of  the  ovum  may  also  be 
caused  by  polypi  or  tumors  of  the  tube;  by  tumors  ex- 
ternal to  the  tube  pressing  upon  it;  by  displacement  and 
hernia  of  the  tube;  by  diverticula  of  the  tube;  or  by  ab- 
normal foldings  of  the  tubal  wall.     Tubal  pregnancy  has 

310 


TUBAL  PREGNANCY. 


311 


occurred  in  tubes  in  which  no  lesions  whatever  could  be 
discovered  by  the  most  careful  examination. 

It  seems  probable  that  all  pregnancies  that  occur  out- 
side of  the  uterus  originate  in  the  Fallopian  tube. 

Pregnancy  may  occur  in  any  part  of  the  tube  from  the 
abdominal  ostium  to  the  uterus. 

Tubal  pregnancy  is  said  to  be  infundibular  when  ges- 
tation begins  in  the  infundibulum  or  in  an  accessory  tube- 


rCHORlOW  10     V(LLi 


Fig.  155 — Tubal  pregnancy,  removed  before  rupture.     The  opening  that  has 
been  cut  in  the  tube  shows  the  chorionic  villi. 


ending.  This  variety  has  also  been  called  tubo-ovarian, 
because  in  time  the  gestation-sac  may  become  adherent 
to  the  ovary  and  be  bounded  by  both  tube  and  ovary. 

The  pregnancy  is  said  to  be  ampullar  when  gestation  be- 
gins in  the  ampulla  of  the  tube.  This  is  the  most  usual 
seat  of  tubal  pregnancy.  It  is  called  interstitial  when 
gestation  begins  in  the  interstitial  portion,  or  that  part  of 
the  tube  in  immediate  relationship  with  the  uterus. 

Changes  in  the  Fallopian  Tube.— During  the  early 
stages  of  tubal  pregnancy — the  first  two  or  three  months 


312      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

— it  seems  probable  that  a  certain  amount  of  hypertrophy 
and  hyperplasia  of  the  muscular  wall  of  the  tube  takes 
place.  The  general  form  of  the  tube  is  spindle-shaped 
(Fig.  155).  There  is  a  marked  increase  in  the  vascularity 
of  the  tube,  most  pronounced  in  the  neighborhood  of  the 
ovum.  The  whole  tube  becomes  turgid  and  swollen. 
The  peritoneal  margin  or  ring  surrounding  the  ostium 
abdominale  becomes  prominent,  and  gradually,  as  has 
already  been  described  under  Salpingitis,  projects  beyond 
the  fimbrise,  contracts,  and  ultimately  hermetically  closes 
the  ostium. 

Inflammation  of  the  peritoneal  covering  of  the  tube 
may  be  present.  Such  inflammation  may  have  preceded 
the  tubal  pregnancy  or  may  have  occurred  as  the  result 
of  the  pregnancy.  It  produces  various  tubal  adhesions 
and  distortions,  and  may  still  more  firmly  close  the  ab- 
dominal ostium.  The  changes  that  take  place  in  the 
mucous  membrane  of  the  tube  and  in  the  developing 
ovum  are  similar  to  those  that  occur  in  the  uterus  in  a 
normal  pregnancy. 

A  variety  of  terminations  occur  in  tubal  pregnancy: 

I.  In  very  exceptional  cases  the  pregnancy  may  con- 
tinue until  full  term,  without  rupture  of  the  tube  taking 
place. 

II.  The  tube  may  rupture.  This  is  by  far  the  most 
usual  occurrence.  The  rupture  may  take  place  into  the 
broad  ligament,  into  the  peritoneal  cavity,  or,  in  the  case 
of  interstitial  tubal  pregnancy,  into  the  uterus. 

III.  Tubal  abortion  may  occur,  the  ovum  being  dis- 
charged through  the  abdominal  ostium  into  the  perito- 
neal cavity. 

IV.  The  ovum  may  be  destroyed  in  the  tube,  gestation 
being  stopped  before  rupture  takes  place. 

Rupture"  of  the  tube  is  the  rule  in  tubal  pregnancy. 
The  time  of  rupture  depends  upon  the  position  of  the 
ovum  in  the  tube.  It  occurs  somewhat  later  in  the  inter- 
stitial variety  than  when  the  ovum  is  situated  in  the  free 
portion  of  the  tube.     Rupture  in  interstitial  pregnancy 


TUBAL  PREGNANCY.  3^3 

commonly  occurs  before  the  fifth  month.  In  the  other 
forms  of  tubal  pregnancy  it  occurs  most  usually  before 
the  end  of  the  third  month.  In  the  latter  class  of  cases 
the  greatest  number  of  ruptures  occur  during  the  second 
month. 

Rupture  is  caused  by  the  gradual  thinning  of  the  tube 
from  distention.  Rupture  may  take  place  suddenly,  a 
large  hole,  through  which  the  ovum  escapes,  being  pro- 
duced; or  the  rupture  and  discharge  of  the  ovum  may 
take  place  gradually  without  causing  any  acute  symp- 
toms. 

When  the  rupture  takes  place  between  the  layers  of 
the  broad  ligament,  the  hemorrhage  is  usually  not  very 
profuse,  as  it  is  controlled  by  pressure  of  the  structures 
that  surround  the  blood.  A  broad-ligament  hematoma 
is  formed.  The  ovum  may  be  destroyed  as  a  result  of 
the  rupture,  and  no  further  lesions  due  to  the  develop- 
ment of  gestation  will  arise.  The  hematoma,  with  the 
ovum,  may  in  time  be  absorbed;  or  suppuration  may  oc- 
cur, with  the  production  of  a  pelvic  abscess;  or  mummi- 
fication, adipoceration,  or  lithoped ion  formation  may  take 
place  in  the  fetus. 

If  the  ovum  is  not  destroyed  by  the  rupture,  it  may  con- 
tinue to  develop  in  the  cavity  formed  by  the  tube  and  the 
broad  ligament.  The  placenta  may  remain  attached  to 
the  inner  surface  of  the  tube,  or  it  may  contract  adven- 
titious attachments  to  any  of  the  surrounding  structures — 
the  surface  of  the  uterus  and  the  pelvic  floor.  The  cavity 
occupied  by  the  ovum  may  continue  to  enlarge,  by  the 
pushing  aside  of  pelvic  and  abdominal  organs,  until  full 
term  is  reached  and  spurious  labor  comes  on. 

In  some  cases  a  secondary  rupture  of  the  gestation-sac 
occurs,  and  the  fetus  is  discharged  into  the  peritoneal 
cavity. 

When  rupture  of  the  tube  into  the  peritoneal  cavity 
occurs,  the  danger  of  fatal  hemorrhage  is  very  great. 
The  majority  of  women  die  within  forty-eight  hours  after 
this  accident,  unless  relieved  by  immediate  laparotomy. 


314      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

There  is  no  surrounding  pressure  to  control  the  hemor- 
rhage, as  in  the  case  of  rupture  into  the  broad  ligament. 
Sometimes  the  escaping  ovum  plugs  the  rent  in  the  tube, 
and  bleeding  is  checked  in  this  way. 

If  the  woman  survive  the  effects  of  hemorrhage,  she 
may  die  from  peritonitis  or  from  suppuration  of  the  he- 
matocele in  the  peritoneal  cavity. 

In  exceptional  cases,  if  the  pregnancy  be  early,  the 
blood  and  the  ovum  may  be  absorbed  by  the  peritoneum, 
and  spontaneous  recovery  occurs. 

If  the  woman  is  not  destroyed  by  the  first  effects  of 
the  rupture,  the  fetus,  surrounded  by  its  membranes, 
may  escape  into  the  peritoneal  cavity,  while  the  placenta 
may  remain  attached  to  the  tube  and  gestation  may  con- 
tinue. It  is  very  doubtful  whether  the  fetus  will  continue 
to  live  if  it  escapes  into  the  peritoneum  free  of  the  mem- 
branes. There  is  no  evidence  that  an  early  ovum  may 
escape  into  the  cavity  of  the  abdomen  and  develop  on  the 
peritoneum. 

If  the  fetus  does  not  survive,  it  may  be  absorbed  by  the 
peritoneum  or  mummification  may  occur. 

Tubal  abortion  means  the  separation  of  the  ovum  from 
the  tube-wall,  and  its  partial  or  complete  discharge 
through  the  ostium  abdominale  into  the  peritoneal  cav- 
ity. The  accident  is  accompanied  by  hemorrhage  into 
the  tube  and  thence  into  the  peritoneal  cavity. 

Tubal  abortion  is  most  likely  to  occur  during  the  early 
weeks  of  pregnancy  (the  first  and  the  second  months), 
before  the  abdominal  ostium  has  become  closed. 

It  is  probable  that  tubal  abortion  is  much  more  fre- 
quent than  is  generally  supposed.  According  to  Sutton, 
tubal  abortion  was  probably  the  cause  of  the  peritoneal 
hematocele  in  many  cases  in  which  the  bleeding  was 
attributed  to  other  origin,  as  reflux  of  menstrual  blood 
from  the  uterus  and  simple  hemorrhage  from  the  tube. 

In  tubal  abortion  the  loss  of  blood  into  the  peritoneum 
may  be  so  great  that  the  woman  is  destroyed.  In  other 
cases  death  results  from  peritonitis  and  suppuration  of 


Fig.  156. — Extra-uterine  pregnancy;  tubal  abortion.  The  bleeding  is  checked  by  a  large 
coagulum  distending  and  thinning  out  the  tube ;  the  fimbriated  opening  is  greatly  distended, 
but  the  greater  diameter  of  the  clot  in  the  ampulla  prevents  its  escape.  Wall  of  tube  aver- 
aging i  milhmeter  in  thickness.  Operation.  Recovery,  July  7,  1896.  Natural  size.  (Kelly. 
Copyright,  1898,  by  D.  Appleton  &  Co.) 


i'l';.  157. ^Coagulum  turned  out,  showing  a  cast  of  the  tube  extending  u))  into  the  isthmus. 
(Jn  its  surface  lies  the  fetus.     Natural  size.      (Kelly.     Copyright,  1898,  by  D.  Appleton  &  Co.) 

315 


3i6       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

the  hematocele.  And,  finally,  in  a  good  many  cases  the 
blood  and  ovum  may  be  absorbed,  and  recovery  takes 
place.  Sometimes,  at  operation,  the  ovum  is  found  in 
the  peritoneal  cavity  without  any  blood.  The  blood  had 
either  been  small  in  amount  and  quickly  absorbed,  or 
there  had  been  no  escape  of  blood  into  the  peritoneum. 
Blood-clot  is  usually  found  in  the  Fallopian  tube  after 
tubal  abortion.  The  ostium  may  become  closed  and  a 
hematosalpinx  may  result. 

When  the  ovum  is  destroyed  in  the  tube  before  rupture 
takes  place,  the  fetus  and  the  blood  may  be  absorbed;  or 
mummification,  adipoceration,  or  lithopediou-formation 
may  result;  or  suppuration  may  occur,  with  the  forma- 
tion of  a  py ©salpinx;  or,  if  death  of  the  fetus  happens  in 
the  early  weeks,  the  tube  may  be  found  closed  at  the 
ostium  abdominale,  and  filled  with  blood  in  which  no 
fetus  may  be  detected.  Such  cases  have  been  repeatedly 
described  as  hematosalpinx,  the  real  origin  of  the  condi- 
tion in  pregnancy  not  being  known.  The  fetus  had  been 
absorbed  or  broken  up  and  scattered  through  the  blood- 
mass.  Careful  microscopic  examination  of  the  tube  re- 
veals the  true  condition — a  destroyed  tubal  pregnancy 
with  hemorrhage  into  the  tube.  As  has  already  been 
said,  hematosalpinx  not  caused  by  tubal  pregnancy  is 
very  rare. 

Coincidently  with  the  development  of  the  tubal  preg- 
nancy there  occur  enlargement  of  the  body  of  the  uterus 
and  decidual  transformation  of  the  endometrium. 

The  enlargement  of  the  uterus  varies  a  great  deal  ac- 
cording to  the  position  of  the  tubal  pregnancy  and  the 
course  of  its  development.  The  interstitial  variety  is  ac- 
companied by  the  greatest  uterine  enlargement.  When 
the  tubal  gestation  has  reached  full  time  the  uterus  may 
measure  from  4.  to  'j}4  inches  in  length. 

The  increased  size  of  the  uterus  is  most  marked  in  the 
long  diameter.  The  change  of  shape  does  not  resemble 
that  which  occurs  in  normal  pregnancy. 

The  uterus  also  becomes  softer  in  tubal  pregnancy,  and 


TUBAL  PREGNANCY.  317 

the  cervix  softens  somewhat,  though  not  so  much  as  in  a 
uterine  pregnancy. 

If  the  woman  and  the  fetus  survive  the  many  dangers 
that  accompany  the  progress  of  tubal  gestation,  the 
development  of  the  fetus  will  go  on  to  full  term,  and 
then  the  phenomenon  of  spurious  labor  will  come  on. 

In  spurious  labor  there  are  a  series  of  periodical  pains 
that  resemble  those  of  normal  labor.  The  pains  may  last 
from  a  few  hours  to  several  days.  They  may  cease,  and 
reappear  after  varying  intervals. 

Hemorrhage  usually  takes  place  from  the  uterus.  After 
the  spurious  labor  the  uterine  discharge  may  be  of  the 
same  character  as  that  seen  after  normal  labor. 

It  is  probable  that  the  fetus  always  dies  after  spurious 
labor.  The  liquor  amnii  is  absorbed,  the  gestation-sac 
shrinks,  and  changes  take  place  in  the  fetus  similar  to 
those  already  referred  to.  It  may  become  mummified  or 
converted  into  adipocere  or  a  lithopedion.  In  this  condi- 
tion it  may  remain  in  the  abdomen  for  many  years.  A 
mummified  fetus  that  had  been  carried  for  fifty  years  has 
been  removed  post-mortem  from  a  woman  aged  eighty- 
two. 

Rarely,  after  spurious  labor  the  gestation-sac  ruptures 
and  the  fetus  is  discharged  into  the  peritoneum,  the  va- 
gina, or  the  large  intestine,  whence  it  is  born  through 
the  anus. 

The  symptoms  of  tubal  pregnancy  are  in  some  cases 
similar  in  all  respects  to  those  of  normal  uterine  preg- 
nancy. In  extremely  rare  cases  the  woman  has  reached 
full  term  in  ignorance  of  any  unusual  condition.  Usually, 
however,  the  early  occurrence  of  some  of  the  accidents 
of  tubal  gestation  attracts  her  attention.  Before  such 
accidents  or  complications  arise  there  are  most  frequently 
no  subjective  symptoms  to  excite  any  suspicion  of  the 
peculiar  form  of  pregnancy.  Changes  in  the  skin,  in  the 
nipples,  in  the  nervous  and  circulatory  systems,  and  in 
the  gastro-intestinal  tract  may  resemble  those  of  normal 
pregnancy,  and  are  subject  to  the  same  variations. 


3i8      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Mammary  changes  accompanied  by  the  secretion  of 
milk  occur  in  tubal  pregnancy.  These  changes  are, 
however,  less  pronounced  than  in  uterine  gestation.  The 
vagina  may  undergo  changes  similar  to  those  of  normal 
pregnancy;  it  becomes  soft,  relaxed,  and  altered  in  color, 
and  pulsation  of  vessels  may  be  felt  in  the  walls. 

It  should  always  be  remembered,  however,  that  tubal 
pregnancy  may  occur  without  the  presence  of  any  of  the 
signs  of  pregnancy.  Women  in  perfect  health,  thought- 
less of  pregnancy,  have  died  of  acute  hemorrhage  from  a 
ruptured  tubal  gestation — the  first  symptom  of  this  con- 
dition. 

The  changes  in  menstruation  vary  a  great  deal.  Men- 
struation usually  ceases  when  tubal  pregnancy  begins, 
though  not  with  the  same  regularity  as  in  normal  preg- 
nancy. 

Sometimes  menstruation  continues  for  a  few  months 
and  then  ceases.  In  other  cases  menstruation  is  arrested 
for  the  first  few  months,  and  occurs  with  greater  or  less 
regularity  during  the  latter  months  of  pregnancy.  There 
may  be  an  irregular  discharge  of  blood  throughout  the 
whole  course  of  gestation. 

In  the  blood  discharged  from  the  uterus  there  may  often, 
be  found  pieces  of  decidual  tissue  of  various  size.  Some- 
times the  w'hole  decidual  membrane  of  the  uterus  may 
be  expelled  in  one  mass.  In  any  suspected  case  the  blood 
should  always  be  carefully  examined  for  such  decidual 
membrane.  All  shreds  of  tissue  should  be  submitted  to 
careful  microscopic  examination.  The  woman  should  be 
questioned  in  regard  to  the  passage  of  such  tissue  before 
she  came  under  medical  supervision. 

The  woman  often  complains  of  periodical  pains  occur- 
ring in  the  hypogastrium  and  in  the  pregnant  tube. 
They  usually  appear  after  the  second  month,  though  they 
may  begin  earlier.  These  pains  are  thought  to  be  caused 
by  the  contractions  of  the  uterus  and  the  gestation-sac. 

The  abdominal  enlargement  in  extra-uterine  pregnancy 
differs  in  several  respects  from  that  of  normal  pregnancy. 


TUBAL  PREGNANCY.  319 

It  is  usually  most  marked  on  one  side  of  the  abdomen 
especially  during  the  first  five  or  six  months. 

Toward  the  end  of  gestation  the  enlargement  becomes 
more  symmetrical  in  the  abdomen,  and  resembles  closely 
that  of  normal  pregnancy. 

In  tubal  gestation,  on  account  of  the  higher  position 
of  the  tube,  bulging  of  the  abdominal  wall  is  likely  to 
appear  somewhat  earlier  than  in  normal  pregnancy.  The 
abdominal  enlargement  in  tubal  pregnancy  does  not  fol- 
low the  same  uniform  progress  that  is  characteristic  of 
uterine  pregnancy. 

Fetal  movements  take  place,  and  fetal  heart-sounds  are 
heard  as  in  normal  pregnancy. 

Bimanual  examination  made  before  rupture  of  the  tube 
will  reveal  the  tubal  enlargement,  the  shape  of  the  tube 
depending,  of  course,  upon  the  position  of  the  tubal 
pregnancy.  The  tubal  enlargement  is  said  by  Veit  to 
have  a  characteristic  soft  feel,  distinct  from  the  hard  or 
fluctuating  enlargements  of  other  forms  of  tubal  disease. 

After  rupture  the  distinct  tubal  tumor  disappears,  and 
the  examiner  feels  a  mass  lying  to  one  side  of  or  behind 
the  uterus.  The  enlarged  tube  may  be  felt  merged  in 
this  mass. 

If  pregnancy  continues  after  rupture,  the  fetal  move- 
ments may  be  felt  and  ballottement  may  be  obtained.  The 
cervix  is  found  to  be  somewhat  softened ;  the  os  may  be 
patulous;  the  uterus  is  soft  and  enlarged.  The  uterine 
enlargement,  however,  is  not  of  the  same  rounded  shape 
as  the  pregnant  uterus,  and  the  size  is  much  less  than 
that  of  corresponding  periods  of  normal  pregnancy. 

It  is  of  great  importance  to  study  the  symptoms  of  the 
accidents  of  tubal  pregnancy.  As  has  already  been  said, 
it  is  usually  the  accident  of  rupture  that  first  directs  the 
woman's  attention  to  the  abnormal  condition. 

The  symptoms  depend  upon  the  seat  of  rupture.    Rup- 
ture of  the  tube  into  the  broad  ligament  is  a  much  less 
serious  accident  than   rupture  into  the  peritoneal  cavity. 
If  the  rupture  into  the  broad  ligament  is  sudden,  the 


320      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

woman  complains  of  sudden  acute  pain  in  the  aflfected 
side.  The  pain  may  extend  to  the  back  and  throughout 
the  pelvis.  The  intensity  and  extent  of  the  pain  depend 
on  the  amount  of  blood  that  escapes.  Sometimes  only  a 
small  hematoma  is  found  in  the  broad  ligament;  at  other 
times  the  blood  burrows  around  the  rectum,  and  symp- 
toms of  pressure  may  arise.  Difficult  defecation  may 
follow.     Retention  of  urine  may  occur. 

The  woman  suffers  from  shock,  and  may  become  some- 
what anemic. 

Bimanual  examination  reveals  the  condition.  The 
broad  ligament  will  be  found  filled  with  a  tense  mass  that 
bulges  into  the  vagina.  The  uterus  is  pushed  to  one  side. 
The  mass  may  extend  behind  the  uterus  and  surround 
the  rectum.  The  upper  outlines  felt  by  the  abdominal 
hand  are  ill  defined. 

The  loss  of  blood  from  simple  rupture  into  the  broad 
ligament  is  not  often  sufficient  to  cause  death.  The  fetus 
may  continue  to  develop,  however,  and  secondary  rup- 
ture into  the  peritoneal  cavity  may  occur. 

Rupture  of  the  tube  or  of  the  gestation-sac  into  the 
peritonea]  cavity  is  a  very  fatal  occurrence.  In  the 
majority  of  cases  death  from  hemorrhage  occurs  within 
twenty-four  hours. 

Unless  the  ovum  plugs  the  rent  in  the  tube,  there  is 
nothing  to  arrest  the  hemorrhage. 

The  woman  is  seized  with  sudden  pain  in  the  side, 
often  described  as  the  sensation  of  "something  giving 
away."  She  sufiers  from  faintness,  acute  anemia,  nau- 
sea, vomiting,  and  collapse.  As  in  other  cases  of  acute 
anemia,  there  may  be  delirium  and  convulsions. 

Bimanual  examination  made  after  intraperitoneal  rup- 
ture reveals  an  indefinite  fulness  or  a  yielding- mass  in 
the  pelvis  behind  the  uterus.  The  blood  free  in  the 
peritoneal  cavity  coagulates  slowly,  and  the  fluid  blood 
or  soft  unrestrained  clots  are  often  very  difficult  to  pal- 
pate. For  this  reason,  at  first  the  examiner  can  feel 
onl}^  an  ill-defined  fulness  in  the  pelvis.     If  the  woman 


TUBAL  PREGNANCY.  321 

survives  and  the  mass  of  blood  becomes  more  solid,  it 
may  then  be  distinctly  palpated  as  a  solid  mass  behind 
the  uterus,  bulging  into  the  vagina,  and  extending  up 
into  the  abdomen.  Though  the  hematocele  may  at  first 
be  difficult  to  define,  yet  the  enlarged  tube  may  usually 
be  palpated,  and  the  ovum  may  sometimes  be  felt  in  the 
midst  of  the  ill-defined  mass  of  blood. 

As  has  already  been  said,  in  rare  cases  rupture  may 
occur  intraperitoneally  or  into  the  broad  ligament  with- 
out producing  any  of  the  severe  symptoms  just  described. 
The  fetus  continues  to  develop,  and  the  woman  will  be 
ignorant  that  rupture  has  ever  occurred.  Between  the 
two  extremes  there  are  all  degrees  of  severity. 

In  tubal  abortion  the  symptoms  resemble  those  of 
intraperitoneal  rupture. 

If  the  fetus  dies  within  the  tube,  the  symptoms  be- 
come those  of  hematosalpinx  or  other  form  of  tubal 
disease. 

Diagnosis. — The  diagnosis  of  tubal  pregnancy  is  not 
often  made  before  rupture,  because  there  are  usually  no 
symptoms  that  direct  the  woman's  attention  to  the  ab- 
normality of  her  condition.  Very  often  she  thinks  that 
she  is  normally  pregnant. 

If  opportunity  is  given  for  examination  before  rup- 
ture, the  diagnosis  may  sometimes  be  made.  The 
woman  presents  the  signs  of  pregnancy.  The  uterus 
may  be  slightly  enlarged,  though  not  of  the  size  or 
shape  normal  for  the  stage  of  pregnancy.  There  is 
a  soft  tubal  tumor. 

Immediately  after  rupture  the  diagnosis  of  the  condi- 
tion must  be  made  from  a  study  of  the  previous  history, 
from  the  present  subjective  symptoms,  and  by  bimanual 
examination. 

If  a  woman  who  had  thought  herself  pregnant  is  sud- 
denly seized  with  pain  in  the  side,  followed  by  anemia 
and  shock,  the  suspicion  of  extra-uterine  pregnancy 
should    be   aroused.     If    bimanual    examination   reveals 

the  hematoma   or  hematocele  in  the  pelvis,  with  tubal 
21 


322       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

enlargement,  the  diagnosis  may  be  made.  Pelvic  hema- 
toma and  hematocele  are  in  nearly  all  cases  caused  by 
tubal  pregnancy. 

If  the  woman  survives  the  rupture  and  the  fetus  con- 
tinues to  develop,  the  diagnosis  becomes  easier  the  more 
advanced  is  the  case. 

It  must  be  remembered  that  amenorrhea  is  not  as 
general  in  tubal  as  in  uterine  pregnancy.  The  woman 
often  gives  the  history  of  irregular  bleeding,  or  of  arrest 
for  a  few  periods  and  then  recurrence  of  menstruation. 
Such  experience  may  lead  her  to  seek  medical  advice 
even  before  rupture. 

The  intermitting  attacks  of  pain  that  are  sometimes 
felt  in  the  affected  tube  may  also  cause  her  to  seek  medi- 
cal advice. 

A  history  of  the  discharge  of  membrane  or  of  .shreds 
of  membrane  is  of  great  value.  If  opportunity  is  afforded 
for  examination  of  such  shreds,  and  decidual  cells  are 
found,  and  if  uterine  pregnancy  may  be  excluded,  there 
is  very  strong  evidence  that  any  mass  in  the  pelvis  is  an 
extra-uterine  gestation. 

It  has  been  advised  to  curette  the  uterus  for  diagnosis 
in  order  to  determine  the  decidual  character  of  the  lining 
membrane.  This  is  good  advice  if  the  operation  is  per- 
formed with  great  care  and  if  we  can  with  certainty  ex- 
clude the  possibility  of  uterine  pregnancy.  If  followed 
indiscriminately,  numbers  of  abortions  would  be  pro- 
duced. Uterine  pregnancy  has  often  been  mistaken  for 
tubal  pregnancy.  The  mistake  is  likely  to  occur  when 
the  fundus  is  drawn  to  one  side  or  is  retroflexed.  Uterine 
pregnancy  may  occur  with  tubal  enlargement  from  other 
cause  than  tubal  pregnancy. 

In  conclusion,  the  diagnosis  of  tubal  pregnancy  before 
the  presence  of  a  fetus  can  be  ascertained  is  based  on  the 
following  considerations:  The  symptoms  of  pregnancy; 
a  tubal  or  pelvic  tumor;  a  slightly  enlarged  though  not 
pregnant  uterus;  discharge  of  decidual  tissue  from  the 
uterus;  the  history  of  the  woman  pointing  to  menstrual 


TUBAL  PREGNANCY.  323 

irregularity,  uterine  discharge  of  shreds,  history  of  pre- 
vious tubal  rupture. 

Treatment. — The  treatment  of  tubal  pregnancy  is 
operative.  It  may  be  considered  under  the  following 
heads:  Before  primary  rupture;  At  the  time  of  rupture; 
After  rupture. 

Before  Primary  Rupture. — If  the  physician  is  so  fortu- 
nate as  to  recognize  a  tubal  pregnancy  before  primary 
rupture,  he  should  without  delay  remove  the  affected 
tube  and  the  contained  ovum.  The  operation  is  simple, 
is  attended  by  no  more  danger  than  that  accompanying 
an  ordinary  salpingo-oophorectomy,  and  the  woman  is 
saved  the  imminent  dangers  associated  with  a  developing 
tubal  pregnancy.  There  are  no  circumstances  under 
which  it  is  proper  to  follow  an  expectant  treatment. 

Most  of  the  cases  of  unruptured  tubal  pregnancy  that 
have  been  operated  upon  were  not  recognized  until  the 
abdomen  had  been  opened.  The  operation  was  per- 
formed under  the  diagnosis  of  pyosalpinx,  hematosal- 
pinx, or  some  other  tubal  disease.  The  cases  show  the 
value  of  the  general  rule  to  operate  without  delay  for 
all  gross  diseases  of  the  tubes. 

At  the  Tiifie  of  Rupture.  — Many  cases  of  tubal  preg- 
nancy are  first  seen  at  the  time  of  rupture.  In  such  cases 
celiotomy  should  be  performed  without  delay.  The  con- 
dition is  most  urgent  in  intraperitoneal  rupture,  but  it  is 
the  safest  rule  to  operate  immediately,  whether  the  rup- 
ture be  intraperitoneal  or  extraperitoneal.  It  is  unwise 
to  wait  for  reaction.  The  physical  depression  in  such 
cases  is  due  more  to  hemorrhage  than  to  shock,  and  it  is 
in  accord  with  general  surgical  principles  to  arrest  hem- 
orrhage at  once. 

Rupture  usually  takes  place  before  the  twelfth  week, 
and  the  whole  product  of  conception,  with  the  tube,  may 
readily  be  removed.  Hemorrhage  usually  ceases  as  soon 
as  the  proximal  and  distal  ends  of  the  ovarian  artery  are 
ligated.  The  ligatures  may  be  placed  about  the  ovarian 
artery,  at  the  pelvic  wall,  and  at  the  uterine  cornu,  as  the 


324      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

first  steps  of  the  operation,  before  any  attempt  is  made  to 
remove  the  mass.  It  may  be  necessary  to  close  the  rent 
in  the  broad  ligament  by  a  second  series  of  sutures. 

After  Riiptuj^e. — If  the  woman  survive,  and  is  first 
seen  after  primary  rupture,  one  of  two  conditions  will  be 
present — a  destroyed  or  a  developing  extra-uterine  preg- 
nancy. If  the  fetus  has  died  and  gestation  has  ceased, 
the  woman  is  exposed  to  the  various  dangers  that  attend 
the  presence  of  such  a  foreign  body  in  the  abdomen.  If 
the  fetus  has  died  during  the  earlier  months,  it  may  have 
been  absorbed  and  spontaneous  cure  may  take  place. 
Even  a  dead  full-term  fetus  has  been  carried  in  the  abdo- 
men for  years  without  producing  a  fatal  result  to  the 
mother.  It  seems  safest,  however,  in  all  such  cases  to 
operate  as  soon  as  the  condition  is  recognized.  The  rules 
of  abdominal  and  pelvic  surgery  apply  to  such  cases. 
The  placenta  of  a  dead  fetus  may  be  removed  without 
fear  of  uncontrollable  hemorrhage. 

If  the  woman  is  seen  after  primary  rupture,  with  a  de- 
veloping gestation,  the  case  presents  much  more  serious 
dangers.  These  dangers  lie  in  the  placenta.  If  the 
pregnancy  has  not  advanced  beyond  the  fourth  month,  it 
is  usually  possible  to  remove  the  whole  of  the  gestation- 
sac,  the  embryo,  and  the  placenta  without  uncontrollable 
hemorrhage.  The  ovarian,  and  if  necessary  the  uterine, 
arteries  may  be  ligated,  and  the  placenta  may  be  removed 
in  one  mass.  The  cavity  of  the  broad  ligament  may  be 
obliterated  by  buried  sutures. 

If  the  gestation  has  advanced  beyond  the  fourth  month, 
it  is  often  impossible  to  remove  the  placenta  without  fatal 
hemorrhage.  Many  women  have  bled  to  death  from  the 
attempt.  The  operator  sometimes  incises  the  placenta  as 
he  enters  the  gestation-sac,  and  is  obliged  to  proceed  with 
its  removal.  In  other  cases  he  starts  to  remove  it,  and 
finds,  too  late,  that  the  hemorrhage  is  beyond  his  control. 
In  the  advanced  months  of  pregnancy  the  sac  and  the 
placenta  may  become  adherent  to  any  of  the  abdominal 
or  pelvic  viscera  and  to  the  large  vessels.     Hemorrhage 


TUBAL  PREGNANCY.  325 

cannot  be  controlled,  as  in  the  earlier  months,  by  liga- 
tion of  the  ovarian  and  uterine  arteries.  The  result  in 
these  cases  is  determined  by  the  ability  of  the  operator. 
A  full-term  living  child,  the  whole  sac,  and  the  placenta 
have  been  successfully  removed.  If  the  attachments  are 
such  that  the  surgeon  considers  it  unsafe  to  attempt  the 
removal  of  the  sac  and  the  placenta,  the  sac  should  be 
incised  and  the  fetus  should  be  removed,  the  cord  being 
divided  between  two  ligatures;  the  sac  should  be  sutured 
to  the  abdominal  incision;  the  cord  should  be  drawn 
through  the  opening,  and  the  sac  packed  with  gauze.  At 
the  end  of  four  or  five  days  the  gauze  pack  may  be  re- 
moved, under  anesthesia  if  necessary,  and  the  placenta 
may  be  taken  away.  There  is  very  much  less  risk  of 
hemorrhage  after  the  lapse  of  a  few  days.  Some  opera- 
tors prefer  to  allow  the  placenta  to  come  away  spontane- 
ously.    This  is  sometimes  necessary. 

It  will  be  seen,  from  this  consideration,  that  the  treat- 
ment of  all  varieties  of  ectopic  gestation  is  operative,  and 
that  the  sooner  the  operation  i^  performed  the  better  for 
the  patient.  Consideration  for  the  life  of  the  child  should 
have  no  influence  in  determining  the  time  of  operation. 


Convoluted- 
Tube 


CHAPTER  XXVII. 
DISEASES  OF  THE   0VARIE5. 

Anatomy. — The  ovaries  vary  a  good  deal  in  size,  with- 
in the  limits  of  health,  in  different  individuals.  It  is 
unusual  to  find  the  two  ovaries  in  the  same  person  exactly- 
alike  in  size,  shape,  and  appearance. 

The  size,  shape,  and  appearance  of  the  ovary  change 
at  the  different  periods  of  life.  In  the  new-born  child 
ui,^^^  the   ovary  is   elongated  and 

lies  parallel  to  the  Fallopian 
tube  (Fig.  158).  In  rare 
cases  this  infantile  shape  of 
the  ovary  may  persist 
throughout  life. 

The  general  shape  of  the 
mature  ovary  is  oval.  The 
average  measurements  are — 
long  axis,  3  to  5  centimeters;  breadth,  2  to  3  centimeters; 
thickness,  12  millimeters;  weight,  100  grains.  These 
measurements  are  subject  to  great  variations.  Henning's 
table  of  measurements  shows  that  the  ovary  of  the  mul- 
tipara is  no  larger  than  that  of  the  virgin. 

After  the  menopause  the  ovaries  shrink  a  great  deal  in 
size,  sharing  in  the  general  atrophy  of  all  the  reproduc- 
tive organs.  The  ovary  of  an  old  woman  may  weigh  but 
15  grains. 

The  healthy  ovary  is  of  a  pinkish  pearly  color.  On  its 
surface  are  seen  small  bluish  areas  that  mark  the  position 
of  unruptured  or  of  recently  ruptured  ovarian  follicles. 
The  ripening  follicles  project  somewhat  from  the  surface 
of  the  ovary,  and  the  old  ruptured  follicles  are  marked  by 

326 


Ovary 

Cervix  Fringes . 

Fig.    158. — Uterus,  tube,   and   ovary 
of  a  child  one  month  old  (Sutton). 


DISEASES  OF  THE  OVARIES.  327 

scars  which  in  time  cover  and  render  irregular  the  whole 
surface  of  the  ovary  (Fig.  159). 

The  surface  of  the  ovary  becomes  more  irregular  and 
wrinkled  after  the  menopause.  The  follicles  disappear, 
until  finally  nothing  is  left  but  a  mass  of  fibrous  tissue 
and  a  few  blood-vessels. 

The  ovary  lies  in  the  posterior  layer  of  the  broad  liga- 
ment.    It  is  attached  by  this  connection  with  the  broad 


Utero-ova  rian 
Ligament 


Cervix 

Fig.  159. — Ovary  (natural  size),  with  the  Fallopian  tube  in  relative   position 

(Sutton). 

ligament  and  by  the  ovarian  and  infundibulo-pelvic  liga- 
ments. 

The  ovarian  ligament  extends  from  the  inner  end  of 
the  ovary  to  the  angle  of  the  uterus  immediately  below 
the  origin  of  the  Fallopian  tube.  This  ligament  varies 
in  length  from  3  to  5  centimeters.  It  is  shortest  in  the 
virgin,  and  longest  in  the  multiparous  woman.  The 
ligament  consists  of  a  fold  of  peritoneum  containing  un- 
striped  muscular  fiber  from  the  uterus. 

The  infundibulo-pelvic  ligament  is  that  part  of  the 


328       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Upper  margin  of  the  broad  ligament  lying  between  the 
distal  end  of  the  Fallopian  tube  and  the  pelvic  wall.  It 
is  about  2  centimeters  in  length.  The  length  is  greatest 
in  the  multiparous  woman. 

The  position  of  the  ovary  is  maintained  by  its  attach- 
ments and  by  its  own  specific  gravity.  The  considera- 
tions that  have  been  discussed  in  regard  to  the  position 
of  the  uterus  also  apply  here. 

The  blood-vessels  are  the  utero-ovarian  arteries  and  the 
ovarian  arteries  and  veins.     The  ovarian  artery  is  homol- 


FlG.  1 60. — View  of  the  posterior  surface  of  the  uterus,  Fallopian  tubes, 
ovaries,  and  broad  ligaments.  The  infundibulo-pelvic  ligament  is  shown  on 
the  left  (Dickinson). 

ogous  to  the  spermatic  artery  in  the  male.  The  course 
of  the  ovarian  veins  has  an  important  influence  upon 
some  pathological  conditions  of  the  ovaries. 

The  right  ovarian  vein  enters  the  inferior  vena  cava  at 
an  acute  angle,  and  at  the  junction  of  the  two  there  is  a 
very  perfect  valve. 

The  left  ovarian  vein  enters  the  left  renal  vein  at  a 
right  angle:  there  is  no  valve  on  this  side.  This  ana- 
tomical difierence  affords  a  probable  explanation  of  the 
greater  tendency  to  congestion  and  prolapse  of  the  left 
ovarv. 


DISEASES  OF  THE  OVARIES.  329 

The  ovary  is  composed  of  connective  tissue  which  sur- 
rounds the  Graafian  follicles,  blood-vessels,  lymphatics, 
nerves,  and  unstriped  muscular  fibers.  The  posterior 
portion,  or  the  free  portion  of  the  ovary,  is  covered  with 
the  germinal  epithelium,  or  modified  peritoneum,  which 
is  continuous  with  the  peritoneum  of  the  broad  liga- 
ment. 

The  ovary  is  divided  into  two  portions,  which  present 
distinct  anatomical,  physiological,  and  pathological  dif- 
ferences. 

The  obphoron  is  the  egg-bearing  portion  of  the  ovary. 
It  corresponds  to  the  free  border  of  the  gland. 

The  paroophoron  corresponds  to  the  hilum  of  the  ovary 
— that  portion  in  relation  with  the  broad  ligament. 

The  paroophoron  contains  no  ovarian  follicles.  It  is 
composed  of  connective  tissue  and  numerous  blood-ves- 
sels. In  the  paroophoron  of  young  ovaries  remnants  of 
gland-tubules — vestiges  of  the  Wolffian  body — may  be 
found. 

Accessory  ovaries  have  been  described  by  several 
writers,  and  their  existence  has  often  been  assumed  to 
account  for  the  persistence  of  menstruation  after  a  sup- 
posed complete  salpingo-oophorectomy.  It  is  very  doubt- 
ful if  a  true  accessory  ovary  has  ever  been  found.  Bland 
Sutton  says:  "As  the  evidence  at  present  stands,  an  ac- 
cessory ovary  quite  separate  from  the  main  gland,  so  as  to 
form  a  distinct  organ,  has  yet  to  be  described  by  a  com- 
petent observer."  It  is  probable  that  the  bodies  that 
have  been  described  as  accessory  ovaries  have  been  more 
or  less  detached  portions  of  a  lobulated  ovary,  or  small 
fibro-myomatous  tumors  of  the  ovarian  ligament.  Ab- 
dominal surgeons  have  had  opportunity  of  examining 
thousands  of  ovaries  at  operation,  and  yet  I  know  of  no 
one  who  has  come  across  a  third  ovary. 


CHAPTER   XXVIII. 
DISEASES  OF  THE  OVARIES  (Continued). 

HERNIA  OF  THE  OVARY. 

Hernia  of  the  ovary  may  take  place  through  the  in- 
guinal ring.  Congenital  hernia  of  the  ovary  is  extremely 
rare.  Bland  Sutton  says  that  there  is  no  properly 
authenticated  case.  Notwithstanding  the  frequency  of 
congenital  hernia  in  infants,  the  ovary  has  not  been 
found  in  the  hernial  sac  at  birth. 

In  cases  that  have  been  reported  as  congenital  hernia 
of  the  ovaries  the  structures  have,  on  microscopical  ex- 
amination, been  found  to  be  testicles,  the  individual 
being  hermaphroditic. 

Acquired  hernia  of  the  ovary  is  of  not  infrequent  oc- 
currence. The  ovary  may  occupy  the  hernial  sac  alone 
or  along  with  other  structures. 

Ovulation  may  occur  normally,  and  conception  may 
take  place.  A  true  corpus  luteum  has  been  found  in  an 
ovary  contained  in  a  hernial  sac. 

The  ovary  may  remain  in  the  inguinal  ring  or  may 
pass  into  the  labium  majus.  In  some  cases  no  trouble 
whatever  arises  from  this  displacement.  Hernia  of  the 
ovary  has  been  found  accidentally  at  autopsy,  having 
been  entirely  overlooked  during  life.  In  other  cases 
swelling  and  severe  pain  may  be  experienced  at  the  men- 
strual periods. 

The  ovary  is  exposed  to  the  dangers  of  congestion  and 
inflammation.  Adhesions  may  result,  and  suppuration 
has  occurred.  In  such  cases  the  symptoms  of  ovaritis 
are  present. 

The  diagnosis  of  hernia  of  the  ovary  is  made  from 
palpation  of  the  gland;  from  the  determination,   by  bi- 

330 


DISEASES  OF  THE  OVARIES.  331 

manual  examination,  of  its  connection  with  the  uterus; 
from  the  characteristic  sickening  pain  experienced  upon 
pressure;  and  from  the  swelling  and  increased  pain  at 
the  menstrual  period. 

The  treatment  is  the  same  as  that  applied  to  hernia 
of  any  other  structure.  The  hernia  should  be  reduced 
if  possible,  and  retained  by  a  truss;  or  the  ring  may  be 
closed  by  radical  operation  for  hernia.  If  the  ovary  is 
adherent,  operation  is  necessary  before  reduction  can  be 
accomplished.  If  the  ovary  is  itself  grossly  diseased,  its 
removal  may  be  necessary. 

PROLAPSE  OF  THE  OVARY. 

Prolapse  of  the  ovary  is  a  downward  displacement  of 
this  organ  behind  the  uterus.  Various  degrees  of  pro- 
lapse occur,  from  a  slight  descent  to  complete  prolapse 
in  the  bottom  of  Douglas's  pouch. 

There  are  two  general  kinds  of  ovarian  prolapse.  In 
one  the  uterus  is  primarily  the  displaced  organ,  and  when 
prolapsed,  retroverted,  or  retroflexed,  it  drags  the  ovaries 
out  of  place  with  it.  Such  cases  have  been  referred  to 
in  discussing  uterine  displacement.  If  the  ovaries  are 
not  adherent,  they  usually  return  to  the  normal  position 
when  the  uterus  is  replaced.  Similar  to  this  kind  of  dis- 
placement of  the  ovary  is  that  which  occurs  in  disease 
of  the  Fallopian  tubes,  which,  when  enlarged,  descend 
and  drag  the  ovaries  with  them.  In  the  other  variety 
the  displacement  is  primary  in  the  ovary,  and  occurs  in- 
dependently of  any  displacement  of  the  uterus  or  other 
structure  to  which  it  is  attached.  It  is  such  prolapse 
that  will  be  considered  here. 

There  are  various  causes  of  ovarian  prolapse.  In 
some  cases  it  is  probable  that  the  position  of  the  ovaries 
in  the  bottom  of  Douglas's  pouch  is  congenital. 

A  sudden  strain  or  effort  is  said  to  have  produced  acute 
prolapse  of  the  ovary. 

Anything  that  increases  the  weight  of  the  ovary  may 


Z2>^       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

cause  its  descent.     Prolonged  congestion,  inflammation, 
or  small  ovarian  tumors  may  result  in  ovarian  prolapse. 

Subinvolution  is  the  most  frequent  cause  of  ovarian 
prolapse.  In  pregnane}'  the  ovaries  become  very  much 
enlarged,  especially  the  left  one.  The  ovarian  ligament 
and  the  infundibulo-pelvic  ligament  become  much  in- 
creased in  length.  If,  after  labor,  involution  is  arrested 
or  is  incbmplete  for  any  reason,  the  conditions  favorable 
for  prolapse  of  the  ovary  will  be  present — increased 
weight  of  the  ovary  and  relaxation  and  lengthening  of 
its  attachments.  Sometimes  the  cause  of  the  prolapse  is 
in  the  ligaments  alone.  The  ovary  may  have  returned  to 
its  normal  size,  while  the  ligaments  may  have  remained 
subinvoluted,  permitting  undue  freedom  of  movement. 

The  left  ovary  is  more  frequently  prolapsed  than  the 
right.  There  are  two  reasons  for  this  difference.  As  has 
just  been  said,  the  left  ovary  becomes  more  enlarged  dur- 
ing pregnancy,  and  therefore  suffers  more  from  subin- 
volution, and  the  arrangement  of  the  veins  on  the  left 
side  is  such  that  venous  congestion  is  very  liable  to 
occur.   • 

When  prolapse  has  existed  for  a  long  time,  secondary 
changes  take  place  in  the  ovary  as  the  result  of  hyper- 
emia, and  the  condition  becomes  further  aggravated. 

Symptoms. — Slight  descent  of  the  ovary  very  often 
causes  no  suffering  whatever.  When,  however,  the 
ovary  is  completely  prolapsed,  lying  in  the  bottom  of 
Douglas's  pouch,  between  the  posterior  wall  of  the 
vagina  and  the  rectum,  well-marked  symptoms  usually 
arise. 

The  woman  suffers  pain  whenever  she  is  in  the  erect 
position.  The  pain  is  increased  by  walking,  probably 
because  the  ovary  is  squeezed  between  the  cervix  and  the 
sacrum.  Coitus  sometimes  causes  intense  pain.  Defeca- 
tion causes  pain.  The  pain  begins  with  the  movements 
of  the  bowels,  and  often  lasts  for  one  or  two  hours  after- 
ward. It  is  dull  and  aching  in  character,  and  is  situated 
in   the  normal  position  of  the  ovary,    radiating  thence 


DISEASES  OF  THE  OVARIES.  333 

throughout  the  pelvis  and  extending  down  the  thighs. 
It  frequently  produces  faintness  and  nausea. 

The  ovarian  pain  is  markedly  increased  at  the  men- 
strual periods. 

The  general  and  reflex  disturbances  produced  by  pro- 
lapse of  the  ovary  are  often  very  pronounced.  There 
may  be  headache,  indigestion,  hysteria,  and  great  mental 
depression.  A  reflex  pain  is  often  felt  in  the  breast  on 
the  same  side  with  the  affected  ovary. 

Bimanual  examination  usually  reveals  the  condition. 
The  prolapsed  ovary  may  readily  be  felt  by  the  vaginal 
finger.  If  the  finger  is  introduced  high  up  behind  the 
cervix,  and  is  then  turned  with  the  palmar  surface  back- 
ward, the  ovary  may  be  caught  between  the  finger  and 
the  sacrum.  The  irregular  surface  of  the  ovary,  due  to 
the  prominent  vesicles  and  the  old  scars,  may  often  be 
felt.  When  the  ovary  is  pressed  upon  there  is  a  charac- 
teristic sickening  feeling  experienced  by  the  woman. 
Sometimes  she  cries  out  with  intense  pain  even  upon  the 
gentlest  pressure  on  the  ovary.  After  witnessing  such 
pain  the  physician  realizes  the  extent  of  the  suffering  ex- 
perienced in  walking,  at  coitus,  and  at  defecation.  If 
the  ovary  is  not  adherent,  it  may  slip  from  the  examin- 
ing finger,  and  perhaps  may  not  be  felt  again  until  a 
subsequent  examination,  after  it  has  returned  to  its  pro- 
lapsed position. 

A  large  prolapsed  ovary  has  often  been  mistaken  for 
the  fundus  uteri,  and  has  caused  the  diagnosis  of  retro- 
flexion to  be  made.  This  mistake  will  not  occur  if  the 
examiner  determines  the  real  position  of  the  uterus  by 
palpation  or  by  the  sound.  The  uterus  may  usually  be 
moved  independently  of  the  prolapsed  ovary. 

Treatment. — The  treatment  of  ovarian  prolapse  de- 
pends upon  the  cause  of  the  condition.  Prolapse  of  the 
ovary  caused  by  uterine  displacement  is  usually  cured  by 
the  treatment  that  restores  the  uterus  to  its  normal  posi- 
tion. 

Prolapse  of  the  ovary  accompanying  tubal  disease  and 


334      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

prolapse  caused  by  small  ovarian  tumors  demand  opera- 
tion and  removal  of  the  tube  and  ovary. 

When  the  ovary  is  not  adherent,  it  may  sometimes  be 
restored  to  its  normal  position,  or  at  least  be  considerably 
elevated,  so  that  the  suflfering  is  much  relieved,  by  pla- 
cing the  woman  in  the  knee-chest  position  and  opening 
the  vagina.  In  this  position  all  the  pelvic  structures  are 
carried  upward. 

A  pledget  of  cotton  or  wool  placed  back  of  the  cervix, 
in  the  posterior  vaginal  fornix,  will  often  give  great 
temporary  relief.  The  cotton  may  stay  in  the  vagina  for 
twenty-four  to  forty-eight  hours. 

The  woman  should  be  advised  to  assume  the  knee- 
chest  position,  allowing  air  to  enter  the  vagina  by  intro- 
ducing the  nozzle-piece  of  the  vaginal  syringe,  once  or 
twice  daily.  The  best  time  is  immediately  before  retir- 
ing at  night,  and  she  should  afterwards  sleep  as  much  as 
possible  on  the  side,  in  the  Sims  position.  She  should 
remain  in  the  knee-chest  position  for  several  minutes — 
until  tired. 

In  addition  to  this  treatment,  the  pelvic  congestion 
should  be  relieved  by  continuous  use  of  saline  laxatives, 
by  hot-water  vaginal  douches,  and  by  occasional  applica- 
tions of  Churchill's  tincture  of  iodine  to  the  vaginal 
vault,  and  the  use  of  the  glycerine  tampon.  If  the  pro- 
lapse has  been  caused  by  subinvolution  of  the  ovary  and 
its  attachments,  such  treatment  may  ultimately  result  in 
cure.  The  enlarged  ovary  diminishes  in  size  and  weight, 
and  its  ligaments  contract  and  regain  tonicity. 

Subinvolution  of  the  uterus  is  often  also  present.  This 
condition  should  be  treated  as  has  already  been  advised. 

In  many  cases  of  ovarian  prolapse  there  have  taken 
place  in  the  ovary  secondary  changes  that  resist  such 
treatment  even  when  most  conscientiously  applied.  The 
physician  is  then  driven  to  the  operation  of  oophorectomy 
as  the  only  method  of  relieving  the  intolerable  suffering. 
This  operation  should  never  be  performed,  however,  until 
other  milder  treatment  has  been  carefully  tried,  and  un- 


DISEASES  OF  THE  OVARIES.  335 

less  the  suffering  of  the  woman  incapacitates  her  for  the 
duties  of  life. 

In  some  cases  in  which  the  ovary  is  not  itself  grossly 
diseased  it  may  be  possible  to  avoid  oophorectomy,  and 
to  correct  the  displacement  by  attaching  the  ovary  by 
suture  to  the  upper  margin  of  the  broad  ligament,  or  by 
shortening  the  infundibulo-pelvic  ligament  by  suture. 
If  the  ovary  has  become  adherent  in  Douglas's  pouch, 
the  condition  can  be  relieved  only  by  operation — celi- 
otomy, and  usually  oophorectomy. 

A  variety  of  pessaries  have  been  invented  for  the  relief 
of  ovarian  prolapse.  They  are  of  but  little,  if  any,  use. 
In  many  cases  the  pressure  of  the  pessary  upon  the  ovary 
renders  its  employment  impossible.  No  pessary  will 
cure  a  simple  prolapse  of  the  ovary.  The  cases  in  which 
the  pessary  does  good  are  those  in  which  there  is  a  pri- 
mary uterine  displacement. 

INFLAMMATION  OF  THE  OVARY;   OOPHORITIS  OR 
OVARITIS. 

Acute  Oophoritis.— In  acute  oophoritis  the  inflam- 
mation may  begin  on  the  surface  of  the  ovary  {peri- 
oophoritis)  and  extend  inward,  or  it  may  begin  in  the 
ovary  itself.  When  the  disease  is  caused  by  extension 
of  the  inflammation  from  the  tubes,  it  usually  begins  as 
a  perioophoritis.  Both  the  follicular  and  interstitial  por- 
tions of  the  ovary  may  be  affected.  When  the  inflam- 
mation is  confined  chiefly  to  the  ovarian  follicles,  it  is 
.said  to  \>^  parenchymatous;  when  the  connective  tissue  is 
.chiefly  affected,  it  is  called  interstitial  oophoritis.  In 
acute  inflammations  all  portions  of  the  ovary  are  usually 
involved  at  one  time. 

The  changes  are  those  that  characterize  inflammation 
of  other  glandular  structures.  The  whole  organ  becomes 
swollen,  hyperemic,  and  edematous.  The  liquor  folliculi 
becomes  turbid;  the  membrana  granulosa  becomes  soft- 
ened and  disintegrated.  The  surface  of  the  ovary  may 
be  covered  with  an  inflammatory  exudate.  In  severe 
.septic  cases  the  whole  ovary  may  become  destroyed,  or 


33^      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

one  or  more  ovarian  abscesses  may  be  formed.  In  less 
severe  cases  the  inflammation  subsides  before  suppuration 
takes  place,  or  goes  on  to  chronic  oophoritis. 

The  usual  cause  of  acute  oophoritis  is  extension  of  in- 
flammation from  the  Fallopian  tube. 

Acute  oophoritis  may  also  occur  as  the  result  of  septic 
infection  carried  by  the  lymphatics  of  the  uterus.  The 
disease  is  not  uncommon  in  puerperal  sepsis.  Here  it 
often  forms  but  a  minor  part  of  a  general  fatal  infection. 

Gonorrhea  may  cause  oophoritis  in  a  similar  way. 

Acute  suppression  of  menstruation  is  said  to  result  in 
inflammation  of  the  ovaries. 

Acute  rheumatism  and  the  eruptive  fevers  may  produce 
oophoritis.  The  disease  of  the  ovaries  is  often  overlooked 
during  the  acute  attack,  while  the  attention  of  the  physi- 
cian is  engaged  by  the  general  affection.  These  diseases, 
occurring  in  childhood,  are  the  probable  causes  of  some 
of  the  damaged  and  chronically  inflamed  ovaries  with 
which  women  suffer  in  later  life.  To  these  diseases  also 
are  to  be  attributed  many  cases  of  arrested  development 
of  the  sexual  apparatus,  the  phenomena  of  which  appear 
only  after  menstruation  has  begun.  The  ovarian  dis- 
ease in  these  cases  may  be  very  insidious.  Decided 
microscopic  changes  have  been  found  in  the  ovarian 
follicles  in  scarlet  fever,  though  to  the  naked  eye  the 
gland  was  unchanged. 

The  syinptoms  of  acute  oophoritis  are  very  often  masked 
by  those  of  accompanying  affections,  such  as  salpingitis 
and  puerperal  sepsis. 

There  may  be  a  chill,  followed  by  fever,  nausea,  and 
vomiting. 

The  pain  is  that  which  characterizes  any  local  pelvic 
inflammation.     It  is  most  intense  in  the  ovarian  regions. 

Bimanual  examination  may  reveal  the  enlarged,  tender 
ovaries,  which  are  very  often  prolapsed  behind  the  uterus. 

The  greatest  gentleness  should  always  be  observed  in 
making  a  vaginal  examination  in  any  case  of  inflamma- 
tion of  the  pelvic  structures,  not  only  to  avoid  inflicting 


DISEASES  OF  THE  OVARIES. 


ZZl 


unnecessary  pain,  but  because  a  much  more  satisfactory 
examination  can  be  made  if  the  woman  does  not  fear  and 
resist  the  examiner. 

Treatment. — The  treatment  of  acute  oophoritis  is  ex- 
pectant. It  is  similar  to  that  already  advised  for  acute 
salpingitis.  The  physician  should  prescribe  absolute  rest 
in  bed;  hot  fomentations  over  the  abdomen;  saline  laxa- 
tives; and  warm  vaginal  douches  of  sterile  water  if  the 
pain  is  not  increased  by  them. 

If  suppuration  occurs,  immediate  laparotomy  with  re- 


FiG.  161.^ — Cystic  ovary. 

moval  of  the  diseased  structures  should  be  practised.  If 
the  acute  inflammation  subside,  subsequent  operation 
may  be  necessary  for  the  chronic  inflammation. 

Chronic  Oophoritis.— Chronic  oophoritis,  like  the 
acute  form,  may  be  either  parenchymatous  or  interstitial. 
Usually  both  the  connective  tissue  and  the  ovarian  folli- 
cles are  involved.  The  disease  is  usually  bilateral.  The 
tunica  albuginea  may  become  much  thickened,  and  adhe- 
sions may  form  between  the  ovary  and  the  adjacent  struc- 
tures. 

In  practice  we  find  chronic  oophoritis  in  two  forms: 
22 


338       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  ovary  may  be  cystic,  filled  with  a  number  of  cysts 
of  varying  size  up  to  that  of  a  marble  (Fig.  i6i).  These 
cysts  are  transformed  ovarian  follicles.  The  walls  are 
thickened,  and  the  ova  and  the  membrana  granulosa 
have  undergone  fatty  degeneration  and  absorption.  The 
fluid  in  the  cysts  may  be  clear,  cloudy,  bloody,  or  gelat- 
inous. Sometimes  the  septa  are  absorbed,  and  several 
cysts  are  thrown  into  one  cavity.  '  The  connective  tissue 
of  the  ovary  is  increased  in  amount. 

The  ovary  becomes  enlarged,  though  it  rarely  exceeds 
the  size  of  a  hen's  ^%%. 


Fig.  162. — Cirrhotic  ovary  from  an  old  maid  forty  years  of  age. 

It  is  probable  that  this  form  of  inflammatory  change  is 
the  origin  of  some  kinds  of  small  ovarian  cystic  tumors. 

In  the  other  form  of  chronic  oophoritis  the  interstitial 
changes  are  most  marked.  There  is  a  decided  increase 
of  the  connective  tissue,  and  a  diminution  of  the  paren- 
chymatous or  follicular  structures.  The  ovary  is  hard 
and  cirrhotic,  and  is  of  a  lighter  or  paler  color  than 
normal;  the  visible  ovarian  follicles  are  few;  the  greater 
part  of  the  ovary  appears  to  be  a  mass  of  wrinkled  con- 
nective tissue;  in  some  cases  the  follicular  structure  is 
confined  to  but  one-quarter  of  the  ovary.  The  changes 
resemble  and  are  similar  to  those  that  take  place  physio- 
logically  in   the  ovaries  of  old  women  (see  Fig.    162). 


DISEASES  OF  THE  OVARIES.  339 

Between  these  two  types  of  cystic  and  cirrhotic  ovaries 
various  forms,  combinations  of  the  two,  may  occur.  The 
ovary  upon  one  side  may  be  cystic,  upon  the  other  cir- 
rhotic. 

The  causes  of  chronic  oophoritis  are  various.  The 
condition  may  persist  after  the  subsidence  of  acute 
oophoritis.  It  is  usually  secondary  to  salpingitis.  There 
are  very  few  .cases  of  chronic  salpingitis  that  are  not  ac- 
companied by  some  form  of  oophoritis.  The  disease 
may  be  chronic  from  the  beginning.  It  may  develop 
slowly  from  septic  or  gonorrheal  infection  from  the 
uterus.  It  may  result  from  subinvolution  or  prolapse  of 
the  ovary. 

It'  may  result  from  immoderate  sexual  irritation,  and 
from  unnatural  gratification  of  the  sexual  impulse. 

It  seems  probable  also  that  chronic  ovaritis  may  occur 
as  the  result  of  celibacy  or  sterility.  The  unceasing 
menstrual  congestions  of  the  virgin  or  the  sterile  woman, 
which,  as  has  already  been  pointed  out,  seem  to  predis- 
pose the  woman  to  fibroid  changes  in  the  uterus,  seem 
likewise  to  develop  the  growth  of  connective  tissue  in 
the  ovary.  Virgins  between  the  ages  of  thirty  and  forty 
often  present  hard  cirrhotic  ovaries  with  decided  diminu- 
tion of  the  follicular  elements.  The  condition  is  often 
associated  with  a  fibroid  state  of  the  uterus,  this  organ 
being  indurated  from  interstitial  fibroid  deposit,  or  pre- 
senting one  or  more  subperitoneal  nodules. 

Symptoms. — The  most  prominent  symptom  of  chronic 
oophoritis  is  pain.  The  disease  is  usually  bilateral,  and 
the  pain  affects  both  ovarian  regions;  it  is,  however, 
usually  more  marked  upon  the  left  side.  The  pain  is  in- 
creased by  the  erect  position  and  by  exercise,  defecation, 
and  coitus.  Pain  at  defecation  and  coitus  is  most  marked 
when  ovarian  prolapse  accompanies  the  inflammation. 

The  pain  is  increased  at  the  menstrual  period.  It  is 
most  intense  immediately  before  and  at  the  beginning  of 
the  flow.  If  the  bleeding  is  profuse,  the  pain  is  often 
relieved. 


340      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Menorrhagia  often  accompanies  chronic  oophoritis,  and 
seems  to  occur  chiefly  with  the  cystic  variety  of  the  dis- 
ease. As  most  cases  of  oophoritis  are  accompanied  by 
endometritis  and  salpingitis,  it  is  difficult  to  determine 
how  important  a  part  in  the  production  of  the  menor- 
rhagia  is  played  by  the  ovarian  disease.  Reflex  pain  in 
the  region  of  one  or  both  breasts,  usually  the  left,  is  often 
complained  of 

The  reflex  disturbances  caused  by  chronic  oophoritis 
form  a  very  important  part  of  the  woman's  suffering. 
Loss  of  appetite,  digestive  disturbances,  nausea,  and 
vomiting  occur.  Hysteria,  profound  mental  depression, 
and  various  cerebral  derangements  take  place.  Sterility 
may  be  caused  by  chronic  oophoritis  if  the  ovarian  cap- 
sule becomes  so  thickened  that  rupture  of  ovarian  follicles 
cannot  take  place. 

Bimanual  examination  should  be  performed  with  great 
gentleness.  The  condition  of  the  ovary  may  be  most 
satisfactorily  determined  in  those  cases  in  which  the 
ovarian  lesion  is  the  chief  trouble  and  in  which  the  tubes 
and  other  pelvic  structures  are  not  coincidently  inflamed. 
If  the  ovary  is  felt,  it  is  found  to  be  very  tender  and  usu- 
ally enlarged.  In  cases  of  long-standing  interstitial  in- 
flammation the  ovary  may  be  below  the  usual  size.  Pal- 
pation is  very  easy  if  the  ovary  is  prolapsed  in  Douglas's 
pouch. 

Chronic  oophoritis  rarely  recovers  spontaneously.  The 
woman  may  have  periods  of  relief,  but  the  symptoms  may 
all  recur  after  some  indiscretion  or  unusual  exercise. 
Suffering  usually  diminishes,  and  may  in  time  cease,  after 
the  menopause,  when  atrophy  takes  place  and  menstrual 
congestions  have  stopped. 

Treatment. — Chronic  oophoritis  usually  requires  oper- 
ative treatment  (salpingo-oophorectomy),  because  it  is 
associated  with  disease  of  the  tubes.  In  other  cases  a 
great  deal  may  be  accomplished  without  operation,  and 
the  woman  may  be  tided  over  the  period  of  menstrual 
life  until  permanent  relief  is  secured  at  the  menopause. 


DISEASES  OF  THE  OVARIES.  341 

This  palliative  treatment  is  usually  applicable,  how- 
ever, only  to  those  women  who  are  not  dependent  for  a 
living  upon  their  own  labor.  It  is  best  to  begin  the  treat- 
ment by  putting  the  woman  to  bed  forone  or  two  months; 
to  administer  daily  massage;  to  maintain  mild  purgation 
with  saline  purgatives;  to  make,  once  a  week,  applica- 
tions of -Churchill's  tincture  of  iodine  to  the  vaginal 
vault,  followed  by  the  glycerin  tampon;  and  to  give  hot- 
water  vaginal  injections  twice  a  day. 

If  there  is  any  disease  of  the  uterus,  such  as  laceration 
of  the  cervix  or  endometritis,  this  should  be  treated  first. 

After  the  woman  leaves  her  bed  the  douches,  saline 
laxatives,  and  vaginal  applications  should  be  continued. 
Absolute  rest  in  the  recumbent  posture  should  be  pre- 
scribed at  the  menstrual  periods,  and  at  other  times  if 
the  ovarian  pain  becomes  severe.  Coitus  should  be  for- 
bidden during  the  treatment.  If  the  woman  is  unable 
to  begin  the  treatment  by  prolonged  rest,  the  subsequent 
part  of  the  treatment  advised  here  may  be  followed. 

This  treatment  always  does  good  for  a  time.  Unfortu- 
nately, its  results  are  not  often  permanent.  The  old  pain 
and  suffering  return  as  soon  as  the  woman  ceases  to  be 
under  medical  care.  If  the  inflammatory  changes  have 
become  well  established,  no  permanent  good  results  from 
any  medical  treatment.  This  is  especially  true  in  those 
cases  in  which  the  original  causative  state  of  things  con- 
tinues after  treatment  is  given  up.  If  the  cirrhotic 
ovaries  are  the  result  of  celibacy,  medicine  can  be  but 
palliative. 

Working-women  are  unable  to  obtain  the  proper  medi- 
cal treatment,  especially  when  the  prospect  of  cure  is 
doubtful,  and  therefore,  if  their  suffering  incapacitates 
them,  must  be  subjected  to  the  operation  of  oophorec- 
tomy. 

In  any  case  oophorectomy  should  be  advised  if  the  suf- 
fering persists  after  carefully  tried  medical  treatment. 


342       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

APOPLEXY   OF  THE  OVARY. 

Hemorrhage  may  take  place  either  into  an  ovarian 
follicle,  in  which  case  it  is  called  follicular  hemorrhage; 
or  it  may  take  place  into  the  ovarian  stroma;  to  this 
condition  the  term  ovarian  apoplexy  is  applied. 

Hemorrhage  into  the  follicles  is  usually  small  in 
amount,  the  distended  follicle  rarely  exceeding  the  size 
of  a  hickory-nut.  In  case  of  cystic  degeneration  of  the 
ovary  small  blood-filled  cysts  may  be  present,  formed  by 
the  fusion  of  several  follicular  cysts.  Occasionally  the 
amount  of  blood  in  the  follicle  is  enough  to  cause  its  rup- 
ture. If  the  follicle  should  rupture  into  the  peritoneum, 
a  small  hematocele  would  result.  If  the  follicle  ruptures 
into  the  ovarian  stroma,  ovarian  apoplexy  occurs. 

Follicular  hemorrhage  and  ovarian  apoplexy  are  most 
liable  to  occur  during  the  congestion  of  a  menstrual 
period. 

Such  hemorrhages  are  not  infrequent  in  the  acute 
fevers  and  in  scurvy.  The  symptoms  of  the  condition 
are  in  no  way  characteristic.  If  the  exact  state  of  the 
ovary  were  known  from  previous  examination,  follicular 
hemorrhage  or  apoplexy  might  be  suspected  from  the  de- 
tection of  a  sudden  ovarian  enlargement  and  pain  unac- 
companied by  symptoms  of  inflammation. 

The  blood  is  usually  absorbed,  and  unless  some  accom- 
panying disease  of  the  ovary  is  present,  spontaneous  re- 
covery will  result. 

OVARIAN  HYDROCELE. 

Ovarian  hydrocele  is  a  rare  disease,  the  true  nature  of 
which  has  been  explained  by  Bland  Sutton.  Most  of 
the  cases  that  have  been  reported  have  been  mistaken 
for  tubo-ovarian  cysts.  The  tubo-ovarian  cyst  has 
already  been  described.  It  is  a  cyst  that  results  from  in- 
flammatory disease  of  the  tube,  and  is  formed  by  the 
union  of  the  cavities  of  a  closed  Fallopian  tube  and  a 
follicular  cyst  in  the  ovary. 


DISEASES  OF  THE  OVARIES. 


343 


Ovarian  hydrocele  has  a  different  origin.  To  understand 
it  a  brief  reference  to  the  relation  between  the  ovary  and 
the  broad  ligament  is  necessary.  I  quote  from  Bland 
Sutton:  "The  ovary  projects  from,  and  is  invested  by 
the  posterior  layer  of  the  broad  ligament.  When  the 
parts  are  examined  in  sitiL.,  the  ovary  will  be  found  to  lie 
in  or  upon  the  edge  of  a  shallow  recess  in  the  mesosal- 
pinx. This  recess  is  the  ovarian  sac  (Fig.  163).  It 
varies  in  depth;  in  many  it  is  small  and  inconspicuous, 
whilst  in  others  it  is  sufficiently  deep  to  accommodate 


Ovarian 
sac 


Uterus 


J-XGALCOIdBj 


Fig.  163. — Left  Fallopian  tube  from  an  adult  (after  Richard). 

the  entire  ovary.  In  the  virgin  the  ampulla  of  the  tube 
falls  over  the  mouth  of  this  recess  and  conceals  the  ovary. 
This  relation  of  parts  is  usually  disturbed  in  the  first 
pregnancy. ' ' 

Tait^  says:  "  In  a  few  exceptions  I  have  seen  a  cre- 
scentic  double  fold  of  the  posterior  layer  of  the  broad 
ligament  pass  down  behind  the  ovary,  covering  it  like 
the  hood  of  a  '  Nepenthes  '  gland.  In  all  such  cases  the 
women  have  been  sterile,  probably  because  this  hood  has 
prevented  the  application  to  the  ovary  of  the  opening  of 

*  Diseases  of  the  Ovaries,  1883,  p.  6. 


344       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

the  oviduct.  I  have  seen  this  arrangement  give  great 
trouble  in  the  removal  of  small  ovaries."  In  some 
animals  the  ovarian  sac  is  much  better  developed  than  in 
the  human  female.  In  the  hyena  it  forms  a  complete 
tunic  to  the  ovary,  the  cavity  of  the  sac  communicating 
with  the  peritoneum  by  a  small  opening.  In  rats  and 
mice  the  sac  is  complete,  and  the  Fallopian  tube  com- 
municates with  the  ovarian  sac,  but  not  with  the  general 
peritoneal  cavit}'. 

Ovarian  hydrocele  occurs  in  women  when  the  abdom- 
inal ostium  of  the  Fallopian  tube  opens  into  a  well- 
formed  ovarian  sac  and  the  common  cavity  becomes  dis- 
tended with  fluid. 

Sutton  sums  up  the  peculiarities  of  ovarian  hydrocele 
as  follows: 

I.  The  Fallopian  tube  opens  b}'  its  abdominal  ostium 
into  a  sac  on  the  posterior  aspect  of  the  broad  ligament, 

II.  The  tube  is  elongated,  dilated,  and  tortuous,  re- 
sembling a  retort  with  a  convoluted  delivery  tube. 

III.  As  a  rule,  there  is  no  evidence  of  inflammation. 
The  cyst  may  suppurate  should  the  tube  become  affected 
with  salpingitis. 

IV.  In  small  cysts  the  ovary  will  be  found  projecting 
on  the  floor  of  the  sac.  In  larger  specimens  it  will  be 
incorporated  with  the  wall  of  the  sac,  and  in  very  large 
specimens  it  is  unrecognizable. 

An  ovarian  hydrocele  may  attain  considerable  size.  A 
case  has  been  reported  in  which  three  pints  of  straw- 
colored  fluid  were  found  in  the  cyst.  An  ovarian  hydro- 
cele is  sometimes  intermitting,  discharging  its  contents 
through  the  tube  into  the  uterus. 

The  symptoms  of  ovarian  hydrocele  resemble  those  of 
a  small  ovarian  cyst  or  a  tubo-ovarian  cyst. 

The  U^eatmejit  is  celiotomy  and  removal  of  the  tube 
and  ovary,  or,  when  practicable,  the  liberation  of  the 
adherent  end  of  the  Fallopian  tube. 


CHAPTER    XXIX. 
CYSTIC  TUMORS  OF  THE  OVARY. 

The  histogenesis  of  cystic  tumors  of  the  ovary  is  not 
yet  definitely  settled.  Every  structure  that  enters  into 
the  composition  of  the  ovary  has  been  supposed  to  form 
the  starting-point  of  these  tumors.  There  are  many  clas- 
;sifications  of  ovarian  cysts  based  upon  the  clinical,  struc- 
tural, or  genetic  features.  The  classification  given  here 
seems  to  me  to  be  the  best  we  have  at  present  for  the 
practical  physician. 


^i^^^' 


^FlG.   164. — Diagram  representing  the  cyst-regions  of  the  ovary  and  broad 

ligament. 

Cystic  tumors  of  the  ovary  may  be  divided  into  two 
•general  classes: 

I.  Oophoritic  cysts,  which  originate  from  the  oophoron, 
■  or  the  egg-bearing  portion  of  the  ovary. 

II.  Paroophoritic  cysts,  which  originate  in  the  paro- 

.ophoron. 

345 


346       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 
OOPHORITIC  CYSTS. 

Cysts  of  the  oophoron  may  be  subdivided  into  {a)  Fol- 
licular cysts;  {b)  Glandular  cysts;  {c)  Dermoid  cysts. 

Follicular  Cysts. — Follicular  cysts  originate  in  the 
ovarian  follicles.  If  anything  occurs  to  prevent  the 
physiological  rupture  of  a  mature  ovarian  follicle,  a  fol- 
licular cyst  may  be  started.  Such  cysts  begin  as  reten- 
tion-cysts of  the  ovarian  follicles. 

The  condition  is  usually  the  result  of  chronic  inflam- 
mation. The  formation  of  new  connective  tissue  in  the 
ovarian  stroma,  the  thickening  of  the  tunica  albuginea, 


Fig.  165. — Follicular  cyst  of  the  ovary. 


the  presence  of  inflammatory  exudate  upon  the  surface 
of  the  ovary,  may  all  prevent  the  rupture  of  the  follicles. 
In  addition,  the  inflammatory  congestion  of  the  walls  of 
the  follicle  produces  an  increased  exudation  into  the 
ovisac. 

It  seems  probable  that  such  inflammatory  action  may 
also  produce  cystic  distention  in  the  immature  follicles 
that  are  situated  remote  from  the  surface  of  the  ovary. 

Follicular  cysts  may  occur  at  any  age,  though  they  are 
most  common  during  the  period  of  sexual  activity.     The 


CYSTIC  TUMORS  OF  THE  OVARY.  347 

follicular  cysts  may  occur  in  one  or  in  both  ovaries;  usu- 
ally both  ovaries  are  affected. 

Only  one  follicle  may  be  involved,  or  a  large  number 
of  follicles,  in  different  degrees  of  cystic  distention,  may 
be  found  scattered  throughout  the  ovary. 

Frequently  one  follicle  enlarged  to  the  size  of  a  hen's 
egg  is  observed  projecting  from  the  surface  of  the  ovary. 
Sometimes  the  intervening  septa  atrophy,  and  one  large 
cavity  is  formed  by  the  union  of  two  or  more  cystic 
follicles. 

Follicular  cysts  of  the  ovary  do  not  increase  indefinitely 
with  age.  They  are  limited  in  growth,  and  in  this  re- 
spect differ  essentially  from  the  glandular  oophoritic 
cysts.  They  are  usually  about  the  size  of  a  hen's  egg. 
They  rarely  attain  a  size  greater  than  that  of  the  adult 
fist.  Exceptional  cases  have  been  reported  in  which  the 
ovarian  tumor  was  the  size  of  the  adult  head.  The  tumor 
may  be  composed  of  one  chief  cyst-cavity,  while  the  rest 
of  the  ovary  may  present  a  much  less  marked  degree  of 
cystic  distention;  or  a  large  number  of  follicles  may  be 
uniformly  distended  each  to  the  size  of  a  cherry,  forming 
an  ovarian  tumor  as  large  as  a  child's  head. 

When  the  ovarian  follicle  becomes  distended  the  walls 
usually  increase  in  thickness  and  strength. 

The  interior  of  the  cyst  is  smooth.  The  character  of 
the  lining  membrane  varies  with  the  size  of  the  cavity. 
In  small  cysts  it  is  the  membrana  granulosa— columnar 
epithelium.  In  cysts  of  medium  size  the  cavity  is  lined 
with  stratified  epithelium.  In  the  largest  cavities  there 
may  be  no  epithelium  present,  the  lining  membrane  be- 
ing fibrous  tissue. 

The  follicular  cyst  is  usually  filled  with  clear  serum 
having  a  specific  gravity  of  1005  to  1020.  It  resembles 
normal  liquor  folliculi.  The  fluid  may  be  purulent  as  a 
result  of  septic  infection,  or  it  may  be  brown  or  black 
from  the  presence  of  altered  blood.  Ova  are  sometimes 
found  in  follicular  cysts  of  moderate  size.  Sometimes 
hemorrhage  takes  place  into  the  follicular  cyst,  form- 


348      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

ing  a  follicular   blood-cyst,   which  may  attain  the  size 
of  a  man's  fist. 

Cyst  of  the  Corpus  Ltiteum. — A  variety  of  the  follicular 
cyst  is  the  cyst  of  the.  corpus  luteum.  Such  a  cyst  is 
formed  by  the  degeneration  and  cystic  distention  of  a 
corpus  luteum.  These  cysts  are  usually  of  small  size, 
rarely  exceeding  that  of  a  walnut.  The  walls  are  thick 
and  of  a  characteristic  light-yellow  color.  The  cavity  is 
lined  by  a  delicate  membrane.  Cysts  of  the  corpus 
luteum  are  rare  in  the  human  female,  but  are  very 
common  in  some  of  the  lower  animals — the  cow  and  the 
mare. 


Fig.  1 66. — Cyst  of  the  corpus  luteum,  showing  the  yellow  lining  membrane  {a) ; 
b,  small  follicular  cyst. 

The  symptoms  caused  by  follicular  cysts  are  those 
of  pressure  and  ovarian  pain.  The  cyst  may  become 
impacted  and  adherent  in  the  pelvis,  and  may  cause 
pressure.  The  ovarian  pain  is  analogous  to  that  de- 
scribed under  Chronic  Oophoritis.  The  pain  that  ac- 
companies this  form  of  cystic  tumor  of  the  ovary  is  much 
more  marked  than  in  the  case  of  the  larger  kinds  of  ova- 
rian cyst,  which  may  be  unattended  by  any  ovarian  pain 
whatever.  In  some  cases  follicular  cystic  disease  of  the 
ovaries  is  accompanied  by  menorrhagia  or  metrorrhagia 
which  is  only  relieved  by  oophorectomy.  This  symptom, 
however,  is  not  usual. 


CYSTIC  TUMORS  OF  THE  OVARY.  349 

The  diagnosis  of  the  condition  is  made  by  bimanual 
examination  and  by  observation  of  the  clinical  course  of 
the  disease.  The  cystic  disease  is  very  often  bilateral. 
The  ovarian  enlargement  is  slow  in  development  and  is 
always  limited.  A  moderate  maximum  size  is  reached 
and  may  persist  for  years. 

Treatment. — The  only  curative  treatment  of  follicular 
cystic  disease  of  the  ovaries  is  by  operation  and  removal 
of  the  tumor.  Operation  is  required  only  in  those  cases 
in  which  the  suffering  is  great.  The  mere  presence  of 
the  cystic  ovary  does  not  demand  operation,  whether  it 
causes  physical  suffering  or  not,  as  in  the  case  of  the 
cystic  tumors  hereafter  to  be  considered.  It  must  be  re- 
membered, however,  that  it  is  often  difficult  or  impossible 
to  make  a  differential  diagnosis  between  follicular  cyst  of 
the  ovary  and  a  young  glandular  or  papillomatous  cyst, 
and  it  is  very  much  safer  in  all  doubtful  cases  to  adopt 
the  operative  rather  than  the  expectant  plan  of  treatment. 
If,  after  the  abdomen  is  opened,  the  cyst  is  found  to  be 
follicular,  the  ovary  need  not  necessarily  be  removed. 

If,  at  the  time  of  operation,  the  ovary  is  found  to  pre- 
sent but  one  follicular  cystic  cavity,  this  may  be  opened 
and  evacuated  and  part  of  the  wall  may  be  excised.  If 
bleeding  occurs  from  the  edges  of  the  cyst-wall,  it  may  be 
controlled  by  whipping  with  a  fine  continuous  suture  of 
silk  or  catgut.  Some  operators  avoid  this  bleeding  by 
opening  the  cyst  with  the  cautery-knife.  In  any  case 
the  bleeding  is  usually  slight  if  a  thin  portion  of  the  cyst- 
wall  is  selected  for  the  incision.  If  the  ovary  is  filled 
with  a  number  of  cystic  cavities, it  is  safest  to  remove  the 
whole  organ.  If  the  woman  be  young  and  anxious  for 
children,  the  small  cysts  may  be  individually  incised  and 
the  ovary  returned  to  the  abdomen.  This  latter  proceed- 
ing is  especially  desirable  in  case  both  ovaries  are  dis- 
eased. When  but  one  is  affected,  the  surgeon  need  not 
hesitate  so  much  before  performing  oophorectomy. 

If,  as  is  very  often  the  case  in  cystic  disease  of  this 
character,  the  Fallopian  tubes  are  found  closed  by  inflam- 


350     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

matory  adhesions,  salpingo-oopliorectomy  is  usually  indi- 
cated. 

Glandular  Cysts.— Glandular  cysts  are  also  called 
multilocular  ovarian  cysts  or  ovarian  adenomata. 

It  was  formerly  thought  that  all  ovarian  cysts  originated 
in  the  Graafian  follicles.  This  view  has  now  been  given 
up  by  most  pathologists.  The  follicular  cysts  that  have 
just  been  described  never  attain  a  large  size,  and  run  a 
distinctly  different  course  from  the  glandular  cysts  now 
under  consideration. 

The  glandular  cysts  probably  originate  from  the  tybes 
of  Pfliiger.  It  will  be  remembered  that  in  the  embryo 
the  ovary  contains  many  epithelial  tubules  derived  from 
the  germinal  epithelium  that  covers  the  surface  of  the 
ovary.  These  are  the  tubes  of  Pfliiger.  In  the  process 
of  development  they  become  converted  into  Graafian 
follicles.  Abnormally  they  persist,  and  have  been 
found  in  the  ovary  at  an  advanced  age,  as  late  as  the 
seventy-fifth  year.  In  the  newborn  infant  these  tubes 
have  been  found  cystic — the  size  of  a  pea.  Such  cystic 
degeneration  of  persistent  tubes  of  Pfliiger  is  the  probable 
origin  of  glandular  cysts  of  the  ovary.  i\.ccording  to  this 
view,  all  such  cysts  are  due  to  a  congenital  defect.  Some 
are  perhaps  formed  congenitally,  and  remain  stationary 
or  develop  in  later  life. 

The  central  cells  of  the  tubes  of  Pfliiger  soften  and  be- 
come liquefied,  and  the  tube  becomes  distended  into  a 
small  pouch  lined  with  primitive  glandular  epithelium. 

The  outer  surface  of  a  typical  glandular  cyst  of  the 
ovary  presents  a  smooth,  glistening,  silvery  appearance. 
This  appearance  is  subject  to  considerable  variation  ac- 
cording to  the  character  of  the  cyst-contents,  the  thick- 
ness of  the  wall,  and  the  inflammatory  and  necrotic 
changes  that  have  taken  place.  Sometimes  there  are 
ocher-colored  or  brownish  spots  upon  the  surface. 

The  surface  of  the  cyst  is  often  lobulated,  from  the 
presence  of  smaller  cysts  or  a  collection  of  secondary 
cysts  in  the  wall. 


CYSTIC  TUMORS  OF  THE  OVARY.  351 

■  The  wall  of  the  cyst  is  composed  of  fibrous  tissue  con- 
taining elastic  and  unstriped  muscular  fibers.  Traces  of 
normal  ovarian  tissue  may  be  discovered  in  the  cyst-wall. 
Sometimes  a  corpus  luteum  is  found  in  the  wall  of  a  cyst 
of  large  size,  showing  that  ovarian  follicles  may  ripen 
and  rupture,  and  that  conception  may  take  place  even 
though  the  ovary  is  grossly  diseased. 

The  thickest  portion  of  the  cyst-wall  is  that  in  the 
region  of  the  pedicle.  The  thinnest  portion  is  usually 
opposite  the  peduncular  attachment. 

By  careful  dissection  the  wall  may  generally  be  divided 
into  three  layers — an  external  and  an  internal  layer  of 
fibrous  structure,  and  a  middle  layer  of  loose  connective 
tissue.  This  differentiation  is  best  marked  in  the  region 
of  the  pedicle.  In  the  thinnest  part  of  the  cyst  the  coats 
become  blended  into  a  thin,  homogeneo'us,  fibrous  struc- 
ture. 

The  outer  surface  of  the  cyst  is  covered  with  a  layer  of 
endothelial  cells.  This  is  not  a  peritoneal  investment. 
It  is  intimately  connected  with  the  outer  fibrous  coat  of 
the  cyst,  and  cannot  be  stripped  off.  In  this  respect  these 
cysts  differ  from  some  hereafter  to  be  described,  in  which 
there  is  a  distinct  detachable  peritoneal  covering. 

The  blood-vessels  of  the  tumor  are  distinguished 
throughout  the  fibrous  wall.  When  three  lamellae  are 
present,  the  large  arteries  are  found  in  the  middle  layer. 
Lymphatics,  often  of  large  size,  are  also  found  in  the 
cyst-wall. 

The  glandular  cyst  is  always,  at  first,  multilocular;  the 
tumor  is  made  up  of  several  cyst-cavities.  As  the  tumor 
increases  in  size  the  pressure  causes  atrophy  of  interven- 
ing septa,  so  that  two  or  more  cavities  are  thrown  into 
one,  and  the  number  of  loculi  becomes  correspondingly 
diminished.  As  the  cyst  grows,  therefore,  the  tendency 
is  toward  the  unilocular  form.  Careful  examination  of 
a  unilocular  glandular  cyst  will  usually  reveal  the  re- 
mains of  atrophied  septa  upon  the  walls. 

The  epithelial  lining  of  these  cysts  is  usually  composed 


352      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

of  columnar  cells.  In  cavities  of  large  size  the  cells  are 
flattened  by  pressure,  and  in  cavities  of  the  largest  size 
fatty  degeneration  and  atrophy  may  have  taken  place,  so 
that  the  lining  cells  entirely  disappear. 

The  cavities  are  often  lined  with  a  soft,  velvety  mem- 
brane, microscopically  similar  to  mucous  membrane. 
The  columnar  epithelium  dips  below  the  surface  to  form 
complex  mucous  glands.  These  glands  may  become  ob- 
structed, and  secondary  mucous  retention-cysts  are  formed 
in  the  walls  of  the  parent  cyst.  Such  a  mass  of  second- 
ary cysts  is  often  seen  projecting  into  the  Inain  cyst-cav- 
ity or  forming  a  lobulated  prominence  upon  its  outer 
surface. 

Follicular  cystic  degeneration,  such  as  has  already  been 
described,  may  occur  in  the  ovarian  tissue  of  the  wall  of 
the  glandular  cyst,  so  that  a  secondary  group  of  small 
cystic  cavities  may  be  formed. 

It  is  thus  seen  that  the  structure  of  an  oophoritic 
glandular  cyst  may  be  very  complex.  There  may  be  one 
or  more  chief  cyst-cavities,  on  the  walls  of  which  may  be 
discovered  the  remains  of  septa  which  had  formerly  sub- 
divided them.  Projecting  into  the  cavities  may  be  seen 
honeycomb-like  masses  of  secondary  mucous  retention- 
cysts;  while  in  the  walls  of  the  tumor,  perhaps  render- 
ing the  surface  lobulated,  may  be  seen  minor  cyst-cavities 
formed  by  beginning  glandular  cystic  degeneration  or  by 
simple  cystic  degeneration  of  ovarian  follicles  (Fig.  167). 

The  contents  of  a  glandular  cyst  vary  greatly,  not  only 
in  different  cysts,  but  in  the  different  cavities  of  the 
same  cyst.  Pseudomucin,  a  peculiar  mucoid  substance 
excreted  from  the  lining  gland  cells,  is  a  most  important 
constituent  of  the  contents  of  this  cyst,  and  is  almost 
characteristic. 

The  fluid  may  be  thin  and  colorless;  it  may  resemble 
thick,  tenacious  mucus;  it  may  be  oily  or  syrupy  in  con- 
sistency; or  it  may  resemble  transparent  jelly.  It  may  be 
colorless,  yellow,  apple-green,  or  brown  or  black  from  the 
presence   of   decomposed    blood.       As   a    rule,   the  fluid 


CYSTIC  TUMORS  OF  THE  OVARY.  353, 

becomes  thinner  as  the  cyst  increases  in  size  and  age. 
The  change  is  probably  due  to  the  alteration  that  takes 
place  in  the  character  of  the  lining  membrane  under  the 
influence  of  continuously  increasing  pressure. 

The  specific  gravity  of  the  fluid  varies  from  loio  to 
1050. 


Fig.  167. — An  oophoritic  glandular  cyst.  The  section  shows  the  remains  of 
an  atrophied  septum,  a  number  of  follicular  cysts  in  the  wall,  and  to  the  right 
a  group  of  mucous  retention-cysts. 

As  glandular  cysts  of  the  ovary  originate  in  the  free 
border  of  the  gland,  they  are  in  the  great  majority  of 
cases  intra-peritoneal  in  their  growth.  They  grow  into 
the  peritoneal  or  the  abdominal  cavity;  they  do  not  push 
aside  layers  of  peritoneum,  like  the  cysts  that  originate 
between  the  folds  of  the  broad  ligament,  and  which  are 
extra-peritoneal  in  their  development. 

23 


354     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Very  rarely  glandular  cysts  of  the  ovary  have  been 
found  that  grew  between  the  layers  of  the  broad  ligament 
and  were  extra-peritoneal  in  development.  It  may  be 
that  in  such  cases  the  ovary  itself  had  occupied  an  ab- 
normal position. 

The  shape  of  the  ovary  is  very  early  destroyed  by  a 
glandular  cyst.  The  ovarian  tissue  is  incorporated  with, 
and  is  spread  throughout  the  cyst-wall.  In  small  tumors 
the  remains  of  the  hilum  may  be  found  at  the  pedicle. 
In  no  case  is  the  body  of  the  ovary  discoverable  as  a 
distinct  structure  lying  upon  the  surface  of  the  cyst. 

The  pedicle  of  the  cyst  is  composed  of  the  ovarian  lig- 
ament, the  upper  portion  of  the  broad  ligament,  and  the 
Fallopian  tube.  These  structures  are  all  more  or  less 
thickened  and  lengthened  as  a  result  of  the  traction  and 
of  the  altered  nutrition  produced  by  the  growing  cyst. 

The  vessels  of  the  pedicle  that  are  derived  from  the 
ovarian  and  uterine  arteries  are  of  various  size.  The 
arteries  rarely  exceed  the  size  of  the  radial  artery. 

Glandular  cysts  are  of  unlimited  growth.  They  in- 
crease in  size  until  they  destroy  the  woman  by  direct 
pressure.     They  literally  crowd  her  out  of  existence. 

The  size  they  may  attain  is  determined  only  by  the 
powers  of  resistance  of  the  woman  and  the  distensibility 
of  the  abdominal  walls.  Glandular  cysts  have  been  re- 
moved that  weighed  200  pounds. 

The  shape  of  the  glandular  cyst  is  approximately 
spherical.  If  is  often  distorted  by  pressure,  and  portions 
of  the  tumor  may  represent  a  mould  of  parts  of  the  pel- 
vic or  posterior  abdominal  walls. 

The  glandular  cyst  is  usually  unilateral.  The  propor- 
tion of  cases  in  which  both  ovaries  are  affected  seems  to 
be  about  4  per  cent. 

In  some  cases,  when  both  ovaries  are  affected,  the  cysts 
may  become  fused,  so  that  a  single  tumor  is  formed,  at- 
tached by  two  distinct  pedicles.  Operation  in  such  cases 
is  often  very  embarrassing. 

The  glandular  cvst  is  the  most  common  form  of  ovarian 


CYSTIC  TUMORS  OF  THE  OVARY.  355 

tumor.  It  may  occur  at  any  time  of  life  from  childhood 
to  old  age.  It  is  most  common  between  the  ages  of 
twenty  and  fifty. 

Dermoid  Cysts. — A  dermoid  cyst  of  the  ovary  is  cha- 
racterized by  the  presence  of  skin  and  cutaneous  appen- 
dages. Dermoid  cysts  are  found  in  various  parts  of  the 
body,  but  they  occur  most  frequently  in  the  ovary.  Of 
188  dermoid  cysts  reported  by  Lebert,  129  occurred  in 
the  ovary. 

Dermoid  cysts  comprise  from  4  to  5  per  cent,  of  all 
ovarian  tumors. 

Simple  ovarian  dermoids  are  usually  of  small  or  mod- 
erate size,  varying  from  the  size  of  a  hen's  &^^  to  that  of 
the  adult  head.  The  cysts  rarely  contain  more  than  8 
pints  of  fluid. 

Dermoid  cysts  may  become  larger  by  fusion  with  gland- 
ular cysts  or  as  the  result  of  inflammation.  Dermoid  cysts 
are  usually  unilateral;  both  ovaries  are  affected  in  about 
20  per  cent,  of  the  cases.  They  are  primarily  unilocular. 
Sometimes  two  or  more  dermoid  cysts  spring  from  the 
same  ovary,  and  these  contemporaneous  cysts  may  be- 
come united,  and  the  contiguous  walls  may  atrophy  so 
that  the  cavities  communicate. 

Dermoid  cysts  of  the  ovary  have  been  found  at  all  ages 
— in  the  fetus  of  eight  months  and  in  women  over  eighty 
years  of  age.  They  are  observed  most  frequently  from 
the  fifteenth  to  the  forty-fifth  year. 

The  external  appearance  of  the  dermoid  cyst  differs 
from  that  of  the  glandular  cyst.  It  is  dull  and  often 
yellowish  or  brownish  in  color. 

Upon  the  internal  surface  of  the  cyst  is  found  a  mem- 
brane which  looks  like  skin  and  which  has  a  similar 
structure.  The  skin  may  cover  the  whole  of  the  surface 
of  the  cavity,  or  it  may  be  restricted  to  a  small  area,  and 
with  the  underlying  tissue  form  a  prominence  of  the  cyst 
wall — the  so-called  parenchyma  body.  This  body  is  com- 
posed of  tissue  derivatives  of  one,  two,  or  all  three  layers 


356     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

of  the  blastoderm  from  the  surface  inward — the  ectoderm, 
mesoderm,  and  entoderm. 

The  following  cutaneous  appendages  are  found:  hair, 
sebaceous  glands,  sweat-glands,  teeth,  mammae,  horn, 
nails.  The  cyst  may  also  contain  bone,  unstriped  mus- 
cle, and  tissue  resembling  brain-matter. 

The  hair  may  arise  from  the  whole  surface  of  the  cyst, 
or  tufts  of  various  length  may  be  found  growing  from 
slight  prominences  of  the  surface.  The  hair  is  usually 
short;  it  is  sometimes  found,  however,  varying  in  length 
from  4  or  5  inches  to  5  feet. 

There  seems  to  be  no  relation  between  the  color  of  the 
hair  of  the  dermoid  and  that  upon  the  external  surface 
of  the  body  of  the  individual.  The  hair  in  an  ovarian 
dermoid  of  a  negress  has  been  found  of  a  blonde  color. 

The  hair  changes  in  color  with  age,  and  in  an  old 
woman  may  become  white. 

The  hair  is  constantly  shed,  and  the  cyst  may  contain 
a  large  quantity  of  short  loose  hair  mixed  with  the  other 
contents.  Sometimes  the  shed  hair  is  found  rolled  up  in 
balls  of  sebaceous  matter. 

Sebaceous  glands  and  sweat-glands  are  usually  nu- 
merous. 

Teeth  may  be  found  free  in  the  cyst-cavity,  or  they 
may  be  attached  to  bone  or  cartilage  within  the  cyst-wall, 
while  the  crowns  project  into  the  cavity;  or  they  may  lie 
completely  imbedded  in  the  wall.  They  are  often  well 
formed,  though  they  may  be  faulty  in  development  and 
shape.  They  are  usually  few  in  number,  ranging  from 
one  to  ten.  Many  more  teeth  than  this,  however,  are 
sometimes  found;  in  one  case  there  were  300. 

Mammae  are  found  in  various  degrees  of  development. 
In  some  cases  there  are  present  one  or  more  tags  of  skin 
resembling  a  nipple.  In  others  the  mammae  may  be  well 
formed  and  may  contain  glandular  tissue. 

The  bones  appear  as  delicate  laminae  or  spiculae  in  the 
cyst-wall.  They  often  present  a  striking  resemblance 
to  the  flat  bones  of  the  skull  and  the  jaw-bones. 


CYSTIC  TUMORS  OF  THE  OVARY.  357 

The  contents  of  a  dermoid  cyst  vary  in  consistency. 
All  the  substances  discharged  from  the  lining  membrane 
enter  into  their  composition.  They  may  consist  of  a 
thick  oily  fluid  of  a  yellowish  or  brown  color,  or  a  pulta- 
ceous,  semi-solid  mass.  They  resemble  the  contents  of 
a  wen  or  a  sebaceous  cyst.  They  are  usually  filled  with 
loose  hairs  and  exfoliated  epithelium.  Though  the  fatty 
contents  may  be  in  a  fluid  condition  during  life,  yet  they 
solidify  when  exposed  to  the  air  and  after  death. 

In  some  cases  a  dermoid  cyst  has  been  found  in  one 
ovary  while  a  glandular  cyst  was  in  the  other.  Again,  a 
single  ovary  may  be  the  seat  of  a  mixed  tumor  composed 
of  dermoid  and  glandular  cysts.  In  most  of  such  cases 
the  dermoid  forms  a  single  loculus  of  the  tumor.  Some- 
times the  septum  between  the  dermoid  cavity  and  the 
glandular  cystic  cavity  atrophies  and  the  two  cavities 
are  thrown  into  one.  Such  an  occurrence  explains  those 
cases  in  which  the  cavity  of  a  multilocular  cyst  is  found  to 
be  partly  lined  with  skin  which  is  continuous  with  the 
cylindrical  epithelium  characteristic  of  the  glandular 
cyst. 

The  sebaceous  glands  and  the  sweat-glands  in  the  walls 
of  an  ovarian  dermoid  may  become  obstructed  and 
undergo  cystic  degeneration,  forming  in  this  way  groups 
of  secondary  cysts. 

Dermoid  cysts  of  the  ovary  are  usually  intra-peritoneal 
in  their  growth,  like  the  glandular  cysts.  In  some  cases, 
however,  they  develop  between  the  layers  of  the  broad 
ligament,  and  may  assume  any  of  the  positions  charac- 
teristic of  such  extra-peritoneal  growths. 

Teratoma.,  a  very  rare  form  of  ovarian  tumor,  is  an 
atypical  modification  of  the  dermoid,  the  teratoma  bear- 
ing a  relation  to  the  dermoid  similar  to  that  of  carcinoma 
to  adenoma.  While  in  the  dermoid  the  chief  mass  of  the 
tumor  has  a  cystic  character,  the  cystic  cavity  containing 
the  secretions  from  the  lining  epidermal  tissue,  the  tera- 
toma is  for  the  most  part  a  solid  tumor,  and  the  produc- 
tive activity  of  the  tissue  is  a  cellular  hyperplasia. 


358      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

They  appear  as  pedunculated  nodular  tumors,  with  a 
smooth  surface,  usually  reaching  a  large  or  enormous  size. 
The  substance  of  the  tumor  is  composed  of  the  dermoid 
tissue  spoken  of,  formed  into  irregular  masses  of  various 
size,  form,  color,  and  consistency,  separated  by  connec- 
tive-tissue fasciculae  and  infiltrated  with  small  and  minute 
cysts  (dilated  glands  or  degenerated  areas).  The  tumor 
is  characterized  by  an  atypical  arrangement,  form,  and 
structure  of  the  epithelium  (after  the  type  of  a  carci- 
noma) and  an  excessive  growth  of  embryonal  connective 
tissue  (after  the  type  of  a  sarcoma).  It  is  extremely  ma- 
lignant, being  destructive  and  distributed  by  metastasis 
and  implantation. 

It  is  believed  at  present  that  the  dermoid  cyst  and  tera- 
toma of  the  ovary  are  developed  from  the  ovule  within 
the  ovarian  follicle  (Wilms).  The  origin  of  such  a  devel- 
opmental change  is  thought  to  be  an  irritation  of  the 
ovule  cell,  comparable  with  that  of  the  epithelial  cell  in 
carcinoma. 

PAROOPHORITIC  CYSTS,  OR  PAPILLOMATOUS  OVARIAN 

CYSTS. 

There  is  an  interesting  variety  of  ovarian  cysts  which 
is  characterized  by  the  presence  of  papillomata,  or  warts, 
upon  the  inner  surface.  These  cysts  arise  from  the  paro- 
ophoron or  from  the  hilum  of  the  ovary.  Many  theories 
have  been  advanced  to  explain  the  origin  of  these  tumors. 
Pathologists  are  far  from  agreeing  upon  this  subject. 
Perhaps  the  most  popular  view  among  English  and 
American  pathologists  is  that  the  papillomatous  cysts 
originate  from  the  remains  of  the  Wolffian  body  which 
may  persist  in  the  paroophoron  in  various  stages  of  de- 
generation. 

As  paroophoritic  cysts  spring  from  the  hilum  or  the 
attached  portion  of  the  ovary,  and  develop  in  the  direc- 
tion of  least  resistance,  they  very  often  separate  the 
lamellae  of  the  mesovarium  and  invade  the  loose  connec- 
tive tissue  between   the  layers  of  the  broad   ligament. 


CYSTIC  TUMORS  OF  THE  OVARY. 


359 


These  cysts  are  thus  very  often  extra-peritoneal  or  intra- 
ligamentous in  their  development. 

Some  writers  of  experience  state  that  three-fourths  of 
all  papillomatous  tumors  of  the  ovary  are  of  intra-liga- 
mentous  growth.  This  has  not  been  the  experience  of 
the  author.  The  majority  of  the  papillomatous  ovarian 
cysts  that  he  has  seen  have  been  intra-peritoneal  in  de- 
velopment, and  have  had  as  well-defined  pedicles  as  the 
ordinary  multilocular  ovarian  cyst. 


Fig.    1 68. — Papillomatous  cyst  of  the  paroophoron.      The  section  shows  the 
papillomatous  growths  in  the  interior  and  the  relation  of  the  oophoron. 


Cyst-wall. — If  the  papillomatous  cyst  be  intra-peri- 
toneal in  development,  two  layers  of  tissue  may  be  dis- 
tinguished in  its  wall:  an  outer  dense  layer,  composed 
of  laminated  connective  tissue  which  sometimes  contains 
unstriped  muscle-fibers;  and  an  inner  loose  layer  of 
fibrous  tissue.  Both  layers  contain  numerous  blood- 
vessels. 


360      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

If  the  cyst  be  extra-peritoneal  or  intra-ligamentous  in 
its  development,  we  find,  in  addition  to  the  two  layers  just 
described,  an  outer  coat  of  peritoneum  which  is  derived 
from  the  broad  ligament. 

The  internal  surface  of  the  cyst — the  walls  and  the 
papillae — is  covered  by  a  single  layer  of  cylindrical  epi- 
thelial cells,  which  may  become  flattened  by  pressure  in 
the  large  cysts.      The  epithelium  is  often  ciliated. 

Upon  the  interior  of  the  papillomatous  cyst  are  found 
warts  or  papillary  growths.  These  growths  vary  in  size 
from  that  of  a  grain  of  sand  to  that  of  the  fetal  head. 
They  may  be  scattered  over  the  cyst- wall  or  collected  in 
groups.  The  larger  growths  often  form  arborescent, 
cauliflower-like  masses,  which  may  be  so  numerous  and 
luxuriant  that  rupture  of  the  cyst  results. 

In  color  the  papillomata  vary  from  whitish  to  dark 
red  or  black,  according  to  the  vascular  supply.  They 
are  sometimes  \-elIow  as  the  result  of  fatty  degeneration. 
They  are  usually  very  vascular,  and  bleed  freely  when 
manipulated. 

The  papillomata  may  be  sessile  or  pedunculated.  The 
pedicle  is  sometimes  very  long  and  thin.  Calcification 
of  the  papillomata  often  takes  place. 

Papillary  cysts  are  usually  unilocular.  In  any  case  the 
number  of  secondary  loculi  is  much  smaller  than  in  the 
glandular  cyst. 

Fhdd  Contents. — The  fluid  contents  of  the  papilloma- 
tous cyst  differ  considerably  from  those  of  the  glandular 
cyst  of  the  ovary. 

In  the  papillomatous  tumor  the  contents  are  usually 
clear  and  of  a  watery  consistency,  with  a  specific  gravity 
of  from  1005  to  1040.  They  are  not  often  thick,  mucous, 
or  gelatinous  in  consistency,  as  in  the  glandular  cyst. 
The  color  varies  from  light  yellow  to  dark  brown  from 
admixture  of  blood.  As  in  all  cystic  tumors,  the  cha- 
racter of  the  contents  depends  upon  the  accidents  that 
have  happened  during  the  growth  of  the  cyst. 

Papillomatous  cysts  are  more  often  bilateral  than  any 


CYSTIC  TUMORS  OF  THE  OVARY.  361 

other  cystic  tumors  of  the  ovary.'  They  affect  both  ova- 
ries in  from  50  to  75  per  cent,  of  the  cases.  For  this 
reason  the  operator  should  always  carefully  examine  the 
second  ovary  after  removing  an  ovarian  cyst,  for  begin- 
ning cystic  degeneration  may  be  found  in  it  also. 

Papillary  cysts  are  usually  of  smaller  size  and  of  slower 
growth  than  glandular  cysts.  The  papillomata  usually 
perforate  the  cyst  and  invade  the  peritoneum  before  large 
size  has  been  attained.  These  tumors,  therefore,  are  not 
often  seen  of  larger  size  than  the  adult  head. 

Though  papillomatous  cysts  of  the  ovary  are  not  as 
common  as  the  glandular  cystomata,  yet  they  are  by  no 
means  unusual.  The  statistics  of  operators  vary  a  great 
deal.  In  600  ovariotomies  Schroeder  found  50  papillom- 
atous cysts — somewhat  over  8  per  cent.  In  the  ex- 
perience of  the  writer  they  have  been  very  much  more 
frequent  than  this. 

The  papillomatous  cyst  is  the  most  dangerous  cyst 
affecting  the  ovary.  The  danger  lies  in  metastasis  of  the 
papillomatous  growths  to  the  general  peritoneum.  Meta- 
stasis occurs  from  the  perforation  of  the  cyst- wall  and 
the  escape  into  the  peritoneum  of  the  papillomatous 
masses. 

The  tendency  to  rupture  of  the  cyst-wall  is  one  of  the 
characteristics  of  this  form  of  tumor.  The  wall  becomes 
weakened  by  atrophy  or  fatty  degeneration,  or  by  direct 
pressure  of  the  luxuriant  papillary  growths.  These 
growths  make  their  way  to  the  outer  surface  of  the  cyst, 
and  extend  thence  throughout  the  peritoneum;  or,  if  rup- 
ture takes  place,  the  cyst  may  become  so  inverted  that  the 
site  of  each  ovary  is  occupied  by  a  mass  of  papillomata; 
the  formerly  enclosing  cyst  has  disappeared,  and  its  re- 
mains can  be  discovered  only  by  careful  dissection  (Fig. 
169).  vSuch  a  condition  has  undoubtedly  often  been  mis- 
taken for  primary  papilloma  of  the  ovary,  the  real  origin 
in  a  papillomatous  cyst  not  having  been  detected. 

The  .secondary  affection  of  the  peritoneum  is  due  not 
.only  to  continuity  of   tissue,    but  to  implantation  and 


362      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

growth  of  portions  of  papillomata  that  have  become 
broken  off  and  carried  to  different  parts  of  the  peritoneal 
cavity.  Such  secondary  growths  may  extend  through- 
out the  whole  abdomen  from  the  pelvis  to  the  diaphragm, 
covering  any  of  the  viscera.  They  resemble  in  all  re- 
spects the  original  papillomata  found  in  the  interior  of 
the  ovarian  cyst.  They  sometimes  form  cauliflower-like 
masses  as  large  as  the  fist,  and  may  be  palpated  through 
the  abdominal  wall.  They  are  very  vascular,  and  bleed 
profusely  on  being  handled.     The  smallest  particles  of 


Fig.  169. — Double  papillomatous  cyst  of  the  ovary.  The  right  cyst  has  rup- 
tured and  is  turned  inside  out,  showing  a  mass  of  papillomata.  Papillomata 
have  penetrated  the  wall  of  the  left  cyst.  The  peritoneum  has  been  infected, 
and  a  papillomatous  growth  appears  on  the  fundus  uteri. 

papillomata  are  capable  of  infecting  the  peritoneum  or 
other  tissues  in  this  way. 

The  escape  of  a  small  quantity  of  the  cyst-fluid  into 
the  abdomen  during  the  removal  of  the  tumor  may  cause 
subsequent  recurrence  in  the  peritoneum.  Secondary 
development  of  the  growth  in  the  abdominal  cicatrix,  or 
its  appearance  in  the  site  of  puncture  after  tapping,  is 
due  to  the  same  cause. 

Papillomata  of  the  peritoneum  are  usually  accompanied 
by  ascites.  This  is  a  prominent  symptom  in  those  cases 
of  papillomatous  ovarian  cyst  in  which  secondary  infec- 
tion of  the  peritoneum  has  taken  place.     In  rare  cases 


CYSTIC  TUMORS  OF  THE  OVARY.  363 

ascites  is  present,  though  perforation  of  the  cyst  and  in- 
volvement of  the  peritoneum  cannot  be  detected. 

Sometimes  perforation  of  the  cyst  takes  place  into  ad- 
jacent organs,  especially  if  the  growth  be  intra-ligament- 
ous.  In  such  cases  the  papillomatous  masses  may  pro- 
trude into  the  bladder,  the  rectum,  or  the  cavity  of  the 
uterus. 


CHAPTER   XXX. 
CYST5  OF  THE  PAROVARIUM. 

The  parovarium  consists  of  a  series  of  fine  tubules 
lying  between  the  layers  of  the  mesosalpinx.  It  may  be 
seen  in  the  fresh  specimen  by  holding  the  mesosalpinx 
stretched  between  the  eye  and  the  light  (Fig.  145). 

The  typical  parovarium  consists  of  three  parts:  a  series 
of  vertical  tubules;  a  series  of  outer  tubules  free  at  one 
extremity;  and  a  larger  longitudinal  tubule. 

The  vertical  tubules  range  from  five  to  twenty-four  in 
number.  They  converge  somewhat  toward  the  ovary, 
where  they  end  in  blind  extremities  and  become  closely 
associated  with  the  paroophoron.  At  the  other  end  they 
terminate  in  the  laro^er  long^itudinal  tubule. 

The  series  of  outer  tubules  are  called  Kobelt's  tubes. 
They  are  free  and  closed  at  the  distal  extremity,  while  at 
the  proximal  extremity  they  join  the  longitudinal  tubule. 
The  larger  longitudinal  tubule  is  called  the  duct  of 
Gartner.  It  may  sometimes  be  traced  traversing  the 
broad  ligament  to  the  uterus,  and  through  the  walls 
of  this  org^an  and  of  the  vaccina  to  its  termination  at  the 
urethra.  It  corresponds  to  the  vas  deferens  in  the  male. 
When  persistent  in  the  vaginal  wall  it  may  become  the 
starting-point  of  a  vaginal  cyst. 

The  vertical  tubes  of  the  parovarium  are  from  0.3  to 
0.5  millimeters  in  diameter.  They  are  occasionally  found 
lined  with  ciliated  columnar  epithelium.  Usually  they 
contain  a  granular  detritus  representing  the  remains  of 
broken-down   epithelium. 

Cysts  may  arise  from  any  of  the  parts  of  the  paro- 
varium. 

Kobelt's  tubes  frequently  become  distended,  and  form 

364 


CYSTS  OF  THE  PAROVARIUM. 


365 


small  pedunculated  cysts  about  the  size  of  a  pea.  They 
are  of  no  clinical  importance  (Fig.  145).  They  are  often 
observed  in  operations  for  ovarian  disease,  and  are  very 
often  mistaken  for  the  hydatid  or  the  cyst  of  Morgagni 
which  springs  from  the  Fallopian  tube,  and  which  has 
already  been  described. 

The  difference  between   these  two  varieties  of  small 


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Fig.  170.' — Cyst  of  the  parovarium.     There  is  no  distortion  of  the  ovaiy.     The 
Fallopian  tube  has  been  much  elongated. 


cysts  may  be  determined  by  careful  examination  of  the 
point  of  origin  and  by  means  of  the  microscope.  Sutton 
states  that  the  cyst  of  Morgagni  has  muscular  walls  and 
is  lined  by  ciliated  columnar  epithelium.  In  the  cyst  of 
Kobelt's  tubes  the  walls  are  fibrous  and  the  lining  is 
cubical  epithelium. 

Large  cysts  of  the  parovarium  originate  from  the  verti- 


366       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

cal  or  the  longitudinal  tubules,  and  usually  remain  ses- 
sile and  develop  between  the  layers  of  the  mesosalpinx 
and  the  broad  ligament.  As  the  cyst  grows  and  separates 
the  layers  of  the  mesosalpinx,  it  comes  into  close  rela- 
tionship with  the  Fallopian  tube.  This  structure,  being 
held  by  its  uterine  connection  and  the  tubo-ovarian  liga- 
ment, becomes  stretched  across  the  surface  of  the  cyst 
and  very  much  elongated.  The  elongation  of  the  Fallo- 
pian tube  is  a  very  constant  accompaniment  of  parova- 
rian cysts.  The  tube  may'  attain  a  length  of  15  or  20 
inches.  The  fimbriae  may  also  become  much  stretched 
and  elongated  by  the  traction  of  the  growing  cyst,  and 
may  attain  a  length  of  4  inches. 

The  ovary  is  unaffected  unless  the  cyst  be  of  very  large 
size,  in  which  case  the  ovary  may  be  stretched  upon  the 
surface  of  the  cyst,  so  that  its  position  becomes  difficult 
to  determine. 

There  are  two  varieties  of  parovarian  cyst — the  simple 
and  the  papillomatous. 

The  simple  pa7'ovarian  cyst  has  a  very  thin  wall  of  uni- 
form thickness.  In  small  cysts,  less  than  the  size  of  a 
child's  head,  the  wall  may  be  transparent.  It  is  of  a 
light  yellowish  or  greenish  color,  and  the  fine  vessels 
ramifying  upon  the  surface  are  plainly  visible.  As  one 
would  expect  from  the  direction  of  growth,  the  outer  cov- 
ering of  the  cyst  is  peritoneum,  which  is  not  adherent 
and  may  be  readily  stripped  off.  The  middle  coat  is 
composed  of  fibrous  tissue  containing  unstriped  muscle. 
The  lining  membrane  is  ciliated  columnar  epithelium, 
stratified  epithelium,  or  simple  fibrous  tissue,  according 
to  the  size  of  the  cyst.  The  changes  in  the  character  of 
the  epithelium  are  due  to  pressure.  The  cyst-contents 
are  a  clear,  limpid,  opalescent  fluid  of  a  specific  gravity 
below  10 10. 

In  the  papillo77iatous  parovarian  cyst  the  interior  is 
covered  with  warts  or  papillomatous  growths  resembling 
in  every  respect  those  that  occur  in  the  cyst  of  the  paro- 
ophoron, already  described.     The  papillomatous  parova- 


CYSTS  OF  THE  PAROVARIUM.  367 

rian  cyst  exhibits  the  same  clinical  features,  and  is  liable 
to  the  same  accidents,  as  the  paroophoritic  cyst.  It  may 
become  perforated  and  infect  the  general  peritoneum. 

The  walls  of  the  papillomatous  parovarian  cyst  are  some- 
what thicker  than  those  of  the  simple  parovarian  cyst;  the 
fluid  contents  are  not  so  clear  and  limpid,  and  may  con- 
tain altered  blood  that  has  escaped  from  the  papillomata. 

Parovarian  cysts  are  almost  invariably  unilocular. 
Only  a  few  cases  have  been  reported  in  which  two  or 
more  cavities  were  present. 

The  cysts  are  of  small  size,  not  often  exceeding  that 
of  a  child's  head.  They  may,  however,  attain  large  di- 
mensions and  contain  several  quarts  of  fluid. 

Parovarian  cysts  are  of  very  slow  growth,  and  refill 
but  slowly  after  tapping  or  rupture.  On  account  of  the 
thinness  of  the  cyst-walls,  these  cysts  seem  especially 
liable  to  the  accident  of  rupture.  Unless  the  cyst  be 
papillomatous,  the  bland,  unirritating  fluid  is  readily  ab- 
sorbed by  the  peritoneum,  and  the  cyst  may  remain  qui- 
escent for  a  long  period. 

Cysts  of  the  parovarium  occur  most  frequently  during 
the  period  of  active  sexual  life.  Unlike  dermoids  and 
cysts  of  the  oophoron,  they  are  unknown  in  childhood. 

Cysts  of  the  parovarium  are  much  less  common  than 
cysts  of  the  oophoron  and  paroophoron.  In  284  tumors 
of  the  ovary  and  parovarium  operated  upon  by  Olshausen, 
about  II  per  cent,  originated  in  the  parovarium. 

Some  authorities  maintain  that  in  rare  instances  der- 
moid cysts  may  arise  from  the  parovarium. 

The  symptoms  of  parovarian  cysts  resemble  those  of 
ovarian  cysts  of  similar  development.  On  account  of  the 
intra-ligamentous  development  of  the  tumor,  pressure- 
symptoms  may  appear  early.  The  cyst  is  of  such  slow 
growth  that  the  simple  parovarian  cyst  may  exist  for  a 
long  time  without  giving  any  trouble  whatever.  The 
slow  growth  is  the  only  clinical  feature  that  would  enable 
one  to  make  a  diagnosis  between  parovarian  and  ovarian 
cyst. 


368      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

COMPARISON  OF  OOPHORITIC,  PAROOPHORITIC,  AND 
PAROVARIAN  CYSTS. 

The  chief  characteristic  features  of  the  large  cysts  of 
the  ovary  and  the  parovarium — the  glandular  cyst,  the 


<>jM^^ 


Fig.  171. —  Section,  perpen- 
dicular to  the  long  axis  of  the 
Fallopian  tube,  passing  through 
the  tube,  the  parovarium,  and  the 
ovary ;  showing  the  relation  of 
the  structures  to  the  peritoneum 
of  the  broad  ligament. 


Fig.  172. — Section,  perpendicular  to 
the  long  axis  of  the  Fallopian  tube, 
shovi^ing  the  relation  of  an  oophoritic 
cyst  to  the  peritoneum  of  the  broad  lig- 
ament. 


paroophoritic  cyst,  and  the  parovarian  cyst — may  be  tabu- 
lated for  comparison  as  follows: 


Fig.  173. — Section,  perpendicular  to  the  long  axis  of  the  Fallopian  tube, 
showing  the  relation  of  a  paroophoritic  cyst  to  the  oophoron  and  the  peritoneum 
of  the  broad  ligament. 


Glandular  Oophoritic  Cyst. — Intra-peritoneal  in  de- 


CYSTS  OF  THE  PAROVARIUM. 


369 


velopment;  no  peritoneal  investment.     Ovary  destroyed 
early  in  the  course  of  the  disease.     Cyst  multilocular. 

Fluid  contents  thick,  colored;  specific  gravity  greater 
than  loio. 

Tumor  of  rapid  growth. 

Usually  unilateral. 

Fallopian  tube  distinct  from  tumor,  and  not  much,  if 
any,  elongated. 

Paroophoritic  Cyst.— Often  extra-peritoneal  in  de- 
velopment, in  which  case  there  is  a  detachable  peri- 
toneal investment. 

Oophoron  not  at  first  involved  by  the  growth. 

Unilocular. 

Fluid  contents  less  thick  and  viscid  than  in  oophoritic 
cyst. 

Interior  filled  with  papillomata. 

Tumor  usually  of  slower 
growth  than  the  oophoritic 
cyst. 

Very  often  bilateral. 

Fallopian  tube  more  likely 
to  be  involved  than  in  oopho- 
ritic cyst. 

Cysts  of  the  Parovarium. 
— Intra-ligamentous  in  de- 
velopment. Peritoneal  invest- 
ment which  may  be  stripped  off. 
'  Ovary  pushed  aside,  but 
shape  not  affected  unless  the 
cyst  be  very  large. 

Cyst  unilocular. 

Wall  thin.  Fluid  contents  watery,  opalescent;  spe- 
cific gravity  below  loio. 

May  or  may  not  have  papillomata  in  interior. 

Tumor  of  very  slow  growth. 

Usually  unilateral. 

Fallopian  tube  much  elongated  and  stretched  immedi- 
ately over  the  surface  of  the  cyst. 

24 


PftROVARlUM: 


Fig.  174. — Section,  perpendicu- 
lar to  the  long  axis  of  the  Fallo- 
pian tube,  showing  the  relation  of 
a  parovarian  cyst  to  the  ovary,  the 
tube,  and  the  peritoneum  of  the 
broad  ligament. 


CHAPTER   XXXI. 

NATURAL   HISTORY  AND  TREATMENT  OF  OVARIAN 

CYSTS. 

In  the  discussion  of  the  secondary  changes,  the  clin- 
ical history,  and  the  treatment  of  cysts,  the  oophoritic, 
paroophoritic,  and  parovarian  cysts  will  be  considered 
together  under  the  general  heading  of  ovarian  cysts. 

SECONDARY  CHANGES  OR  ACCIDENTS  OF  OVARIAN 
CYSTS. 

There  are  various  accidents  which  may  happen  to  an 
ovarian  cyst  which  have  an  important  bearing  on  the 
clinical  course  of  the  disease.  These  accidents  are:  in- 
flammation and  suppuration;  torsion  of  the  pedicle;  rup- 
ture of  the  cyst. 

Inflammation  and  Suppuration. — Inflammation  of 
an  ovarian  cyst  is  of  very  common  occurrence.  It  seems 
especially  liable  to  happen  in  the  small  cysts  of  pelvic 
growth.  Ovarian  dermoids  are  very  often  inflamed.  The 
inflammation  may  result  in  but  a  few  peritoneal  adhesions 
between  the  outer  surface  of  the  cyst  and  some  of  the 
contiguous  structures,  as  a  loop  of  intestine,  the  bladder, 
the  anterior  abdominal  wall,  the  omentum,  etc.,  or  the 
whole  cyst  may  be  universally  adherent,  so  that  its  re- 
moval is  rendered  most  difficult,  and  in  some  cases  im- 
possible. 

The  operator  should  always  remember  the  possibility 
of  these  adhesions  in  removing  an  ovarian  cyst.  Its  sur- 
face should  be  carefully  examined  as  it  is  dragged  slowly 
through  the  abdominal  incision,  in  order  that  slight 
adhesions  to  delicate  structures  like  the  omentum  and 
the  vermiform  appendix  may  not  be  recklessly  or  un- 
knowingly torn. 

370 


NA  TURAL  HISTOR  Y  OF  O  VARIAN  CYSTS.      371 

The  sources  of  inflammatory  infection  of  an  ovarian 
cyst  are  the  intestinal  tract,  the  urinary  bladder,  and  the 
Fallopian  tube.  Perhaps  salpingitis  is  the  most  frequent 
cause  of  such  inflammation.  Infection  often  comes  from 
the  vermiform  appendix,  which  is  frequently  found  ad- 
herent to  the  surface  of  the  tumor. 

Old  adhesions  usually  contain  blood-vessels,  which  may 
be  of  large  size,  especially  if  they  arise  from  the  intestine, 
the  omentum,  or  the  uterus.  In  some  cases  in  which  the 
tumor  has  become  detached  from  the  pedicle  by  rotation 
or  traction  the  adhesions  have  been  sufficiently  vascular 
to  maintain  the  vitality  of  the  tumor. 

Suppuration  of  ovarian  cysts  is  sometimes  seen.  It 
was  more  frequent  in  the  period  when  these  tumors  were 
treated  by  tapping,  as  infection  occurred  in  this  way. 

Suppuration  is  most  common  in  ovarian  dermoids. 
The  tumor  may  become  adherent  to  surrounding  struc- 
tures, and  may  discharge  its  contents  through  the  bladder, 
the  vagina,  the  rectum,  or  the  abdominal  wall.  A  tooth 
thus  discharged  into  the  bladder  from  a  suppurating  der- 
moid has  in  several  instances  formed  the  nucleus  of  a 
vesical  calculus. 

A  suppurating  ovarian  cyst  sometimes  contains  gas, 
either  from  communication  with  the  intestine  or  from 
decomposition  of  its  contents.  In  such  a  case  the  usual 
tumor-dulness  is  replaced  by  a  tympanitic  note. 

Torsion  of  the  Pedicle,  or  Axial  Rotation.— Ova- 
rian tumors  occasionally  rotate  upon  their  axes,  so  that 
the  structures  that  form  the  pedicle  become  twisted.  The 
severity  of  the  symptoms  that  arise  from  this  accident 
depends  upon  the  degree  of  compression  to  which  the 
vessels  of  the  pedicle  are  subjected  froin  the  torsion. 

The  accident  is  not  now  as  common  as  formerly,  be- 
cause the  tumor  is,  as  a  rule,  now  removed  as  soon  as  it 
is  recognized,  and  many  of  the  accidents  that  were  de- 
scribed as  very  frequent  by  the  older  writers  are  avoided. 
The  many  recorded  cases— chieflv  of  a  date  before  our 
present  surgical  era — show  that  axial  rotation  occurred  in 


372      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

about  lo  per  cent,  of  the  cases  of  ovarian  and  parovarian 
tumors.  Rokitansky  found  torsion  of  the  pedicle  in  12 
per  cent,  of  all  cases  of  ovarian  tumors,  and  in  6  per  cent, 
of  the  cases  it  was  the  cause  of  death. 

The  cause  of  axial  rotation  is  unknown.  It  has  been 
attributed  to  alternate  distention  and  evacuation  of  the 
bladder,  to  the  passage  of  feces  through  the  rectum,  and 
to  a  sudden  jar  or  motion  of  the  body. 

The  accident  is  especially  likely  to  occur  when  an 
ovarian  cyst  complicates  pregnancy  or  when  both  ovaries 
are  cystic.  Torsion  of  both  pedicles  has  been  found  in 
women  suffering  with  bilateral  ovarian  cysts. 

Torsion  of  the  pedicle  is  more  apt  to  occur  in  cysts  of 
medium  and  small  size  than  in  the  large  tumors. 

Torsion  of  the  pedicle  affects  equally  tumors  of  the 
right  and  left  sides.  The  direction  of  rotation  is  usually 
toward  the  median  line,  though  it  may  take  place  in  the 
reverse  direction. 

There  is  considerable  variation  in  the  amount  of  rota- 
tion. In  some  cases  the  pedicle  has  twisted  through  but 
half  a  circle,  while  in  others  twelve  complete  twists  have 
been  found.  A  pedicle  twisted  in  this  way  resembles  a 
rope.  Such  a  high  degree  of  torsion  is  the  result  of  a 
slow  or  chronic  process.  The  rotation  of  the  tumor  takes 
place  so  gradually,  or  the  arrangement  of  the  blood-ves- 
sels in  the  pedicle  is  such,  that  no  appreciable  effect  upon 
the  tumor  is  produced,  and  no  symptoms  arise  from  it. 
The  operator  frequently  meets  examples  of  such  slow 
torsion  in  removing  ovarian  tumors.  In  extreme  cases 
the  twisting  progresses  until  the  blood-supply  through 
the  pedicle  is  arrested,  and  the  cyst  may  become  freed 
from  its  peduncular  attachment.  If  adhesions  had  formed 
to  the  cyst-wall,  the  vitality  may  be  maintained  through 
these  channels;  the  tumor,  in  fact,  becomes  transplanted. 
This  phenomenon  is  most  frequent  with  dermoids. 

Very  different  are  the  phenomena  of  acute  torsion. 
Here  the  vascular  supply  of  the  tumor  is  so  suddenly 
and  markedly  interfered  with  that  most  urgent  symptoms 


NA  TURAL  HISTOR  Y  OF  O  VARIAN  CYSTS.      373 

immediately  arise.  The  interference  with  the  circula- 
tion depends  upon  the  amount  of  the  twist  and  the  cha- 
racter of  the  pedicle.  The  effect  is  first  felt  by  the  veins, 
which  are  more  compressible  than  the  arteries;  the  ven- 
ous blood-current  becomes  obstructed,  while  the  arteries 
remain  open.  Venous  engorgement  of  the  cyst  results; 
extravasation  of  blood  takes  place  in  the  walls,  or  the 
veins  may  rupture  and  hemorrhage  may  take  place  into 
the  cyst-cavity.  Death  from  acute  anemia  may  result 
from  this  cause.  Thrombosis  and  necrosis  of  the  tumor 
may  occur  as  a  result  of  acute  torsion. 

Rupture  of  Ovarian  Cysts. — Rupture  of  an  ovarian 
cyst  is  an  accident  of  not  infrequent  occurrence.  It  is 
probable  that  small  cysts  rupture  and  refill  without  the 
attention  of  the  woman  or  the  physician  being  directed  to 
the  accident.  The  scars  of  old  ruptures  are  frequently 
found  on  the  surface  of  ovarian  cysts.  Wells  found  rup- 
ture of  the  cyst  24  times  in  a  series  of  300  ovariotomies. 

There  are  various  causes  which  predispose  to  rupture 
or  lead  to  it.  As  the  cyst  enlarges,  the  walls  become 
very  thin  as  a  result  of  the  distention.  The  cyst-wall 
may  undergo,  in  places,  retrograde  changes — atrophy  and 
fatty  degeneration.  The  wall  may  become  weakened  as 
a  result  of  suppuration,  thrombosis,  and  the  results  of 
torsion  of  the  pedicle;  and,  as  has  already  been  said,  pap- 
illomatous growths  destroy  the  integrity  of  the  wall  and 
lead  to  perforation. 

The  immediate  cause  of  the  rupture  is  usually  a  sud- 
den jar  or  a  fall.  Sometimes  very  slight  pressure  is 
enough  to  rupture  the  cyst.  The  manipulations  of  a 
physician,  turning  in  bed,  and  coughing  have  caused  this 
accident. 

The  effects  of  rupture  depend  upon  the  character  of 
the  cyst-contents. 

Hemorrhage  may  be  profuse  and  rarely  fatal.  The 
hemorrhage,  however,  is  usually  not  severe,  because  the 
rupture  takes  place  in  the  attenuated  part  of  the  cyst, 
which  is  but  poorly  supplied  with  blood-vessels. 


374       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

If  the  fluid  is  unirritating  to  the  peritoneum  and  con- 
tains but  little  solid  material,  it  is  often  readily  absorbed 
by  the  peritoneum  and  passed  off  by  the  kidneys.  Large 
quantities  of  fluid  may  be  absorbed  and  eliminated  in  this 
way.  A  case  has  been  reported  in  which  the  rupture 
of  a  cyst  was  followed  by  profuse  diuresis  which  lasted 
four  days,  during  which  time  65  pints  of  urine  were  dis- 
charged. 

Another  case  has  been  reported  in  which  the  cyst  rup- 
tured and  refilled  34  times  during  a  period  of  nine  years. 
The  fluid  on  each  occasion  was  absorbed  by  the  perito- 
neum and  discharged  by  the  kidneys  without  in  any  way 
incapacitating  the  woman. 

If  the  cyst-contents  are  septic,  as  is  often  the  case  in 
dermoid  cysts,  fatal  peritonitis  will  result.  The  danger 
of  rupture  of  the  papillomatous  tumors — general  papil- 
lomatous infection  of  the  peritoneum — has  already  been 
described. 

Similar  infection  may  rarely  occur  from  the  escape  into 
the  peritoneum  of  the  colloid  contents  of  a  ruptured 
glandular  cyst.  After  such  an  accident  the  peritoneum 
has  been  found  covered  with  tough  gelatinous  masses,  of 
a  gray  or  yellow  color,  which  reached  the  size  of  a  hick- 
ory-nut. This  condition  has  been  called  myxoma  peri- 
toncEi. 

Very  rare  cases  of  similar  metastasis  from  rupture  of 
dermoid  cysts  have  been  reported.  In  one  case  yellow 
nodules  the  size  of  a  pea,  containing  light-colored  hair, 
were  found  scattered  upon  the  peritoneum. 

It  is  probable  that  when  the  walls  of  an  ovarian  cyst 
are  very  thin,  slow  transudation  of  the  fluid  into  the 
peritoneum  takes  place. 

THE  CLINICAL  HISTORY  OF  OVARIAN  CYSTS. 

The  symptoms  produced  by  ovarian  cysts  depend  upon 
their  size,  their  position,  and  the  accidents  that  may  arise. 
If  the  tumor  be  intra-peritoneal  in  its  development,  the 
woman's  attention  is  usually  first  directed  to  the  patho- 


NA  TURAL  HISTOR  Y  OF  O  VARIAN  CYSTS.      375 

logical  condition  when  the  growth  has  attained  sufficient 
size  to  extend  above  the  pelvis.  The  time  of  the  percep- 
tion of  the  tumor  depends  upon  the  intelligence  and 
powers  of  observation  of  the  woman  and  the  thickness 
of  the  abdominal  wall.  A  cyst  often  attains  a  large  size 
and  reaches  well  up  into  the  abdomen  before  the  woman 
is  aware  of  its  existence.  In  the  papillomatous  cysts 
sometimes  the  first  symptoms  that  attract  the  woman's 
attention  appear  after  the  cyst  has  become  perforated  and 
the  peritoneum  has  become  invaded  by  the  papillomata. 

Pain,  except  that  due  to  pressure  or  inflammation  or 
some  other  accident,  is  not  at  all  characteristic  of  ovarian 
cysts. 

If  the  cyst  be  intra-ligamentous  in  development,  or  if 
it  be  wedged  in  the  pelvis,  the  first  symptoms  of  the  dis- 
ease appear  at  an  earlier  date.  The  intra-ligamentous 
tumors  first  separate  the  layers  of  the  broad  ligament; 
they  push  the  uterus  to  one  side,  and  press  upon  the 
bladder,  ureters,  and  rectum.  The  disposition  of  the 
peritoneum  may  be  altered  in  a  variety  of  ways  by  these 
growths.  They  may  grow  altogether  behind  this  mem- 
brane, becoming  retro-peritoneal,  coming  into  immediate 
relationship  with  the  rectum;  or  they  may  pass  behind 
the  cecum  and  the  ascending  colon,  growing  between 
the  layers  of  the  mesocolon.  They  sometimes  develop 
more  especially  under  the  anterior*  layer  of  the  broad 
ligament,  strip  off  the  peritoneal  covering  of  the  bladder, 
and  come  into  immediate  relationship  with  the  anterior 
abdominal  wall;  so  that  if  laparotomy  is  performed,  the 
operator  will  enter  the  cavity  of  the  cyst  before  he  has 
opened  the  general  peritoneum.  It  is  of  the  greatest  im- 
portance that  the  surgeon  should  be  familiar  with  such 
unusual  ways  of  development  of  these  tumors,  as  the  ope- 
rative difficulties  that  are  encountered  are  most  embar- 
rassing. 

Pressure  upon  the  ureters  occurs  not  only  in  the  cysts 
of  intra-ligamentous  growth,  but  also  in  the  large-sized 
intra-peritoneal  tumors.     It  is  a  frequent  complication. 


376      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

and   the   hydronephrosis   and   kidney-degeneration   that 
result  may  be  the  immediate  cause  of  death. 

Doran  says  that  in  32  cases  out  of  40  autopsies  on 
women  with  large  ovarian  tumors,  kidney  disease,  prob- 
ably caused  by  pressure  of  the  tumors,  was  present.  The 
writer  has  found  a  ureter  distended  to  an  inch  in  diameter 
from  pressure  of  a  papillomatous  cyst.  The  pressure  of 
the  tumor  sometimes  produces  edema  of  the  lower  ex- 
tremities and  of  the  anterior  abdominal  walls. 

The  presence  of  ascites  with  cysts  of  papillomatous 
nature  has  already  been  spoken  of  Though  this  com- 
plication is  especially  characteristic  of  these  tumors,  and 
usually  indicates  peritoneal  involvement,  yet  it  is  some- 
times found  with  the  glandular  and  the  dermoid  cysts. 
In  these  cases  it  is  caused  by  the  direct  mechanical  irri- 
tation of  the  peritoneum  by  the  movable  tumor.  It  ac- 
companies also  freely  movable  solid  tumors  of  the  ovary 
and  pedunculated  fibroids  of  the  uterus. 

Notwithstanding  the  gross  disease  of  the  ovaries,  the 
functions  of  the  uterus  are  in  no  way  specifically  affected 
by  ovarian  cysts.  The  uterus  may  be  pushed  to  one 
side,  pressed  backward  into  the  hollow  of  the  sacrum 
or  forward  against  the  pubis,  but  menstruation  may  not 
be  affected,  and  conception  may  take  place  even  with 
tumors  of  very  large  size. 

In  some  cases  there  is  menorrhagia,  or  continuous 
bleeding,  which  appears  with  the  appearance  of  the  cyst 
and  disappears  after  its  removal.  This  phenomenon  may 
occur  in  old  women  who  have  long  passed  the  meno- 
pause, and  may  excite  the  suspicion  of  coincident  malig- 
nant disease  of  the  uterus.  On  the  other  hand,  men- 
struation may  be  diminished  or  arrested. 

Reflex  disturbances  in  the  breast  may  occur  with  ova- 
rian cysts,  as  in  any  form  of  ovarian  disease.  The  areola 
may  become  pigmented,  the  breasts  swell,  and  a  milky 
secretion  may  be  produced  even  in  young  girls. 

Malignant  degeneration  may  occur  in  any  form  of  ova- 
rian cyst.     It  seems  to  be  most  frequent  in  the  papillom- 


NA  TURAL  HISTOR  Y  OF  O  VARIAN  CYSTS.      377 

atous  tumors,  next  in  the  dermoids,  and  less  frequent  in 
the  glandular  cysts. 

The  rapidity  of  growth  of  ovarian  cysts  varies  a  great 
deal.  The  glandular  tumors  are  of  the  most  rapid  de- 
velopment. They  sometimes  attain  a  very  large  size 
within  a  few  months.  The  rate  of  accumulation  of  the 
fluid  depends  upon  the  intracystic  pressure,  and  is  con- 
sequently greatest  immediately  after  rupture  or  tapping. 
Some  remarkable  cases  of  great  rapidity  of  accumulation 
after  tapping  have  been  reported.  In  one  case  90  pints 
of  fluid  reaccuniulated  in  seven  weeks — a  rate  of  about 
2  pints  a  day.  In  another  case  3^  pints  of  fluid  were 
accumulated  every  day. 

The  enormous  size  attained  by  ovarian  cysts,  and  the 
tremendous  amount  of  fluid  drawn  off"  from  them,  are 
shown  by  the  old  records  of  the  days  when  tapping 
the  cyst  was  the  only  treatment.  A  few  references  will 
illustrate  this.  In  one  case  1920  pints  of  fluid  were 
drawn  off  by  66  tappings  in  a  period  of  sixty-seven 
months.  In  another  case  2787  pints  were  withdrawn  by 
49  tappings.  In  another  case  9867  pounds  were  with- 
drawn by  299  tappings.  The  fluid  in  these  remarkable 
cases  must  have  been  of  low  specific  gravity,  containing 
but  little  solid  matter,  or  the  women  would  have  sooner 
succumbed  from  the  drain  on  the  system. 

The  misery  of  the  women  who  were  slowly  crowded 
out  of  existence  by  these  enormous  tumors,  or  who, 
though  with  life  prolonged  by  tapping,  were  exhausted 
by  the  continuous  drain,  was  depicted  in  their  counte- 
nances. The  expression  was  called  \k\^  fades  ovariana. 
We  do  not  often  see  it  at  the  present  day.  Wells  de- 
scribes it  thus:  "The  emaciation,  the  prominent  or 
almost  uncovered  muscles  and  bones,  the  expression  of 
anxiety  and  suffering,  the  furrowed  forehead,  the  sunken 
eyes,  the  open,  sharply  defined  nostrils,  the  long,  com- 
pressed lips,  the  depressed  angles  of  the  mouth,  and  the 
deep  wrinkles  curving  around  these  angles,  form  together 
a  face  which  is  strikingly  characteristic." 


378      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  natural  duration  of  life  depends  upon  the  charac- 
ter of  the  ovarian  tumor.  A  dermoid  may  exist  from 
childhood  and  give  no  trouble — in  fact,  may  not  be  rec- 
ognized until  some  accident  starts  it  into  rapid  develop- 
ment. Even  then  it  is  of  comparatively  slow  and  limited 
growth,  and  danger  from  it  is  due  to  the  accidents,  such 
as  inflammation  and  suppuration,  to  which  it  is  especially 
liable. 

Though  the  papillomatous  cyst  is  also  of  slow  growth 
when  compared  with  the  glandular  cyst,  yet  the  danger 
here  is  due  to  peritoneal  infection,  which  very  often  takes 
place  before  the  tumor  has,  by  its  size,  begun  to  annoy 
the  woman. 

The  glandular  cyst,  however,  is  of  rapid,  continuous, 
unlimited  growth,  and  usually  destroys  the  woman  with- 
in a  period  of  three  years.  Life  has  been  prolonged 
for  a  much  longer  period  in  some  cases  by  palliative 
treatment  and  tapping.  On  the  other  hand,  life  may  at 
any  time  be  cut  short  by  the  occurrence  of  some  acci- 
dent, such  as  rupture  or  torsion  of  the  pedicle. 

Symptoms  of  the  Accidents  that  occur  in  Ovarian  Cysts. 
— The  symptoms  of  inflammation  are  pain  and.  tenderness 
over  the  surface  of  the  tumor.  The  tenderness  is  often 
limited  to  a  local  area  which  marks  the  position  of  an 
intestinal  adhesion. 

When  suppuration  takes  place,  the  symptoms  indicative 
of  the  presence  of  pus  appear — elevated  temperature,  rapid 
and  feeble  pulse,  exhaustion,  and  emaciation. 

Symptoms  of  Torsion  of  the  Pedicle. — There  are  no 
characteristic  symptoms  of  slow  or  chronic  torsion,  un- 
less, perhaps,  retardation  of  the  growth  of  the  tumor 
appears  as  a  result  of  the  interference  with  the  circu- 
lation. 

The  symptoms  of  acute  torsion  are,  however,  very 
marked.  The  woman  is  seized  with  sudden  and  violent 
pain  in  the  abdomen,  accompanied  by  vomiting  and  col- 
lapse. Sometimes  the  abdomen  becomes  rapidly  increased 
in  size  on  account  of  the  venous  engorgement  of  the 


NA  TURAL  HISTOR  Y  OF  O  VARIAN  CYSTS.      379 

tumor.  If  a  woman  known  to  have  an  ovarian  tumor 
is  thus  attacked,  the  diagnosis  of  torsion  of  the  pedicle 
may  be  made.  The  diagnosis  is  rendered  more  probable 
if  the  woman  is  also  pregnant  or  if  she  has  been  recently 
delivered.  If  the  woman  presents  herself  for  the  first 
time  to  the  physician  with  these  acute  symptoms,  and  he 
finds  by  abdominal  and  pelvic  examination  that  there  is 
an  ovarian  tumor,  he  should  suspect  that  torsion  of  the 
pedicle  has  occurred. 

Rupture  of  the  Cyst. — Rupture  of  an  ovarian  cyst  usu- 
ally follows  a  fall,  a  violent  attack  of  coughing,  vomiting, 
etc. 

The  woman  is  seized  with  sudden  pain  in  the  abdomen, 
with  perhaps  symptoms  of  collapse  and  loss  of  blood. 

The  shape  of  the  abdomen  becomes  quickly  altered 
from  that  characteristic  of  encysted  fluid  to  that  charac- 
teristic of  free  fluid  in  the  peritoneum.  The  alteration 
in  shape  is  so  marked  that  it  may  readily  be  perceived  by 
the  patient. 

These  phenomena  are  followed  by  profuse  diuresis,  or 
perhaps  by  symptoms  of  peritoneal  inflammation. 

If  the  woman  survive,  there  is  a  gradual  reaccumulation 
of  fluid  and  a  return  of  the  abdomen  to  the  former  shape. 

Bxamination. — In  the  early  stages  of  an  ovarian  cyst, 
while  it  is  in  the  pelvic  state  of  development,  bimanual 
examination  will  reveal  the  condition.  The  tumor  lies 
to  the  side,  to  the  front,  or  behind  the  uterus.  The  ute- 
rus may  be  moved  independently  of  the  tumor.  The 
cystic  character  of  the  growth  may  often  be  determined 
by  palpation  ;  fluctuation  may  be  felt  between  the  vagi- 
nal finger  and  the  abdominal  hand.  If  the  tumor  be 
intra-peritoneal,  with  a  pedicle,  it  will  be  found  to  be 
movable,  and  may  be  pushed  out  of  the  pelvis  up  into 
the  lower  abdomen.  If  it  be  intra-ligamentous,  the  range 
of  motion  is  limited,  the  tumor  is  situated  lower  in  the 
pelvis,  and  is  in  closer  relationship  with  the  uterus. 

The  shape  of  the  tumor  is  usually  spherical.  In  a 
multilocular  cyst  the  surface  may  be  lobulated;  in  a  der- 


380      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

moid  cyst  the  pultaceous  character  of  the  contents  may 
sometimes  be  determined  by  pressure  with  the  vaginal 
finger. 

When  the  tumor  has  attained  a  sufficient  size  to  have 
extended  into  the  abdomen,  much  may  be  determined  by 
careful  abdominal  examination.  The  woman  should  lie 
upon  the  back,  and  all  constricting  clothing  should  be 
removed.     The  whole  abdomen  should  be  exposed. 

The  bulging  or  prominence  caused  by  the  cyst  is  usu- 
ally apparent  in  a  thin  woman.  It  commonly  occupies 
the  middle  of  the  abdomen,  but  when  not  very  large  may 
lie  to  either  side. 

Palpation  reveals  the  smooth,  spherical  character  of 
the  growth,  or  the  lobulated  surface  from  the  presence  of 
secondary  cysts.  Perhaps  an  area  of  marked  tenderness 
may  be  discovered,  which  often  shows  the  seat  of  perito- 
neal inflammation  and  adhesion.  In  the  papillomatous 
tumors  that  have  become  perforated,  irregular  masses  of 
papillary  growths  may  sometimes  be  felt  through  the 
abdominal  walls,  situated  either  on  the  surface  of  the 
tumor  or  in  some  other  portion  of  the  abdomen.  The 
association  of  such  masses  with  a  cystic  tumor  of  the 
ovary  and  ascites  renders  the  diagnosis  of  papillary  cysts 
very  certain. 

If  the  tumor  is  non-adherent  and  of  medium  size,  it  may 
be  moved  from  side  to  side  or  upward  in  the  abdomen. 

Fluctuation  may  often  be  elicited  by  palpation,  and 
is  most  marked  in  the  unilocular  cysts  with  thin  con- 
tents. If  the  contents  be  thick,  as  in  many  of  the  gland- 
ular cysts,  or  if  the  cyst  be  multilocular,  fluctuation  may 
not  be  obtained.  The  wave  of  fluctuation  is  interfered 
with  by  intervening  septa. 

Percussion  reveals  a  central  area  of  flatness  which 
marks  the  most  prominent  part  of  the  tumor.  Intestinal 
resonance  may  be  obtained  above  and  to  the  sides  of  the 
cyst,  and  in  some  cases  below  it.  In  instances  of  this 
kind  a  central  area  of  flatness  is  found  surrounded  by  a 
rinof  of  resonance. 


NA  TURAL  HISTOR  Y  OF  0  VARIAN  CYSTS.      381 

This  phenomenon  is  very  dififerent  from  that  which 
appears  if  the  fluid  accumulation  is  free  in  the  perito- 
neum. In  the  latter  case  the  fluid  gravitates  to  the  flanks 
when  the  woman  is  upon  her  back,  and  the  intestines 
float  to  the  front,  so  that  there  is  a  central  area  of  reso- 
nance, with  dulness  to  the  sides.  In  the  very  unusual 
cases  in  which  gas  is  contained  in  the  cyst-cavity  the 
area  of  flatness  will  be  replaced  by  an  area  of  a  tympan- 
itic note. 

If  the  woman  sits  up  or  lies  on  either  side,  the  relation 
between  the  areas  of  flatness  and  resonance  is  unaltered 
in  the  case  of  an  ovarian  cyst,  while,  as  is  well  known, 
if  the  fluid  be  free  it  will  gravitate  to  the  most  depend- 
ent portion  of  the  abdomen. 

Auscultation  reveals  nothing  of  importance  in  regard 
to  ovarian  tumors.  It  is  of  value  in  enabling  one  to  make 
a  differential  diagnosis  between  an  ovarian  tumor  and 

pregnancy. 

Vaginal  examination  in  the  case  of  a  large  tumor  shows 
the  character  and  the  position  of  the  lower  portion  of  the 
growth,  and  sometimes  enables  the  physician  to  deter- 
mine upon  which  side  the  tumor  had  started.  In  rup- 
tured papillomatous  cysts  the  papillary  masses  may  some- 
times be  felt  behind  the  uterus  when  they  cannot  be 
detected  by  the  abdominal  hand. 

The  details  of  the  natural  history  and  pathological 
features  already  given  will  often  enable  the  physician  to 
make  a  differential  diagnosis  among  the  different  kinds 
of  ovarian  cysts.  Such  a  differential  diagnosis,  however, 
is  of  no  importance  whatever,  as  all  such  tumors  require 
similar  operative  treatment. 

To  discuss  the  subject  of  the  differential  diagnosis  of 
ovarian  cysts  from  other  pelvic  and  abdominal  tumors 
would  require  a  consideration  of  all  the  pathological 
growths  that  may  occur  in  the  abdomen.  About  every 
form  of  abdominal  tumor  has  been  mistaken  for  ovarian 
cyst.  Differential  diagnosis  is  here  also  of  but  little  im- 
portance at  the  present  day  if  the  examiner  is  able  to 


382       A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

exclude  pregnancy,  phantom  tumor,  and  fat.  Operation 
is  indicated  in  practically  all  morbid  growths  of  the  ab- 
domen, with  the  exception  of  inoperable  malignant  dis- 
ease; no  surgeon  should  undertake  any  abdominal  ope- 
ration unless  he  is  prepared  to  deal  with  any  condition 
that  may  be  found. 

The  difficulty  of  making  a  differential  diagnosis  is  well 
illustrated  by  many  cases  that  have  been  recorded,  in 
which  it  was  impossible  to  determine  the  true  nature  of 
the  tumor  even  after  the  abdomen  had  been  opened. 

It  is  of  the  greatest  importance  to  exclude  pregnancy. 
Many  women  have  been  subjected  to  the  operation  of 
celiotomy  because  the  pregnant  uterus  was  mistaken  for 
an  ovarian  tumor.  Women  themselves  often  intention- 
ally mislead  the  physician,  especially  if  the  pregnancy  is 
illegitimate.  They  will  even  carry  the  deception  so  far 
as  to  go  upon  the  operating  table  with  the  full  knowledge 
that  they  have  deceived  the  surgeon  as  to  their  condition. 

The  physician  should  always  remember  the  possibility 
of  pregnancy  in  examining  any  form  of  abdominal  tumor 
in  women.  The  mistakes  that  have  happened  have  usu- 
ally been  the  result  of  carelessness  or  ignorance  on  the 
part  of  the  physician,  though  some  of  the  most  experi- 
enced operators  have  made  this  error. 

The  separation  of  the  uterus  by  bimanual  examination 
as  distinct  from  the  abdominal  tumor  is  the  most  valuable 
point  in  the  differential  diagnosis. 

The  complication  of  pregnancy  with  an  ovarian  cyst 
renders  the  diagnosis  more  difficult. 

It  is  easier  to  make  a  differential  diagnosis  between  an 
ovarian  cyst  and  pregnancy  than  between  some  forms  of 
uterine  fibroid  and  pregnancy. 

Repeated  examinations  are  often  necessary.  It  is 
always  advisable,  in  any  case,  to  make  two  or  more  ex- 
aminations before  subjecting  the  woman  to  operation. 
Much  which  was  not  at  first  apparent  may  be  learned  by 
several  days  of  watching  and  repeated  examination. 

Phantom  tumor  is  a  rare  condition.    A  woman  imagines 


TREA  TMENT  OF  O  VARIAN  CYSTS.  383 

that  she  is  suffering  from  a  tumor  and  that  her  abdomen 
is  increasing  in  size.  The  condition  is  likely  to  occur  at 
the  menopause,  and  there  may  readily  be  some  physical 
grounds  for  the  woman's  suspicions,  because  there  may 
be  a  constantly  increasing  accumulation  of  fat  in  the  ab- 
dominal walls  and  the  omentum. 

The  diagnosis  is  usually  easily  made.  Careful  palpa- 
tion and  percussion  fail  to  reveal  any  pathological  mass 
in  the  abdomen  or  any  abnormal  area  of  dulness.  In 
these  cases  the  abdomen  is  often  rendered  prominent  by 
intestinal  tympany.  If  any  difficulty  is  experienced  at 
the  examination,  the  woman  should  be  etherized.  If  a 
satisfactory  diagnosis  cannot  be  made,  the  case  should  be 
watched.  Several  cases  have  been  reported,  and  there 
are  probably  many  unreported,  in  which  no  tumor  was 
found  after  the  abdomen  had  been  opened. 

A  fat  abdominal  wall  or  omenturh  has  often  been  mis- 
taken by  the  woman,  and  not  infrequently  by  the  physi- 
cian, for  a  tumor.  These  cases  are  often  obscure;  indeed, 
all  the  difficulties  of  examination,  in  case  a  tumor  be 
present,  are  very  much  increased  by  the  enormous  de- 
posits of  fat  that  are  often  present  in  the  abdomens  of 
women. 

Careful  examination,  sometimes  with  anesthesia,  and, 
if  necessary,  prolonged  watching  should  be  practised. 
If  a  fold  of  the  abdominal  wall  be  picked  up  between 
the  hands,  it  will  often  show  how  much  of  the  abdom- 
inal enlargement  is  due  to  fat. 

TREATMENT  OF  OVARIAN  CYSTS. 

Tapping. — At  one  time  the  universal  method  of  treat- 
ing cystic  tumors  of  the  ovary  was  by  tapping,  or  punc- 
ture through  the  abdominal  wall.  Many  women  were 
subjected  to  this  proceeding  a  very  great  number  of 
times,  and,  though  not  cured,  were  enabled  to  drag  on  a 
miserable  existence  until  death  resulted  from  exhaustion 
or  from  some  accident  to  the  cyst.  In  a  few  cases  the 
cyst  refilled  very  slowly,  relief  being  experienced  for  sev- 


384      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

eral  years  before  a  second  tapping  became  necessary.  In 
still  fewer  cases  the  tapping  seemed  to  be  curative,  the 
tumor  never  reappearing  after  it  had  been  evacuated. 
Such  cases  were  so  unusual  that  they  should  have  no  in- 
fluence whatever  in  determining  the  method  of  treatment. 
In  the  great  majority  of  instances  the  cyst  rapidly  re- 
filled. Sometimes  the  fluid  accumulated  with  such  ra- 
pidity that  evacuation  became  necessary  every  few  days. 
Referring  again  to  the  old  records,  we  find  a  case  which 
was  tapped  664  times  in  thirteen  years — once  in  about 
seven  days! 

If  the  cyst  were  multilocular,  tapping  furnished  but 
partial  relief. 

The  proceeding  itself  was  attended  by  serious  dangers. 
Dr.  Fock  of  Berlin  in  1856  stated  that  25  out  of  132 
women — or  i  in  5)^ — died  within  some  hours  or  a  few 
days  after  the  first  tapping.  Another  operator  lost  9  out 
of  64  cases — or  very  nearly  i  in  7 — within  twenty-four 
hours  after  the  first  tapping.  The  chief  mortality  oc- 
curred in  the  cases  of  multilocular  tumors.  Tapping 
the  unilocular  tumors  was  attended  by  much  less  danger. 

The  sources  of  danger  from  tapping  were  the  following: 
hemorrhage  from  puncture  of  a  vessel  in  the  cyst- wall; 
septic  or  other  infection  of  the  peritoneum;  and  inflam- 
mation or  suppuration  of  the  cyst. 

The  majority  of  the  women  died  in  consequence  of 
peritoneal  infection. 

The  danger  arose  not  only  from  septic  infection  of  the 
peritoneum,  but  from  papillomatous  or  other  infection 
from  the  escape  into  the  peritoneal  cavity  of  some  of  the 
cyst-contents.  Reference  has  already  been  made  to  the 
occurrence  of  the  papillomatous  infection  at  the  site  of 
puncture  in  the  abdominal  wall. 

At  the  present  day  tapping  an  ovarian  cyst  with  the 
hope  of  cure  is  never  practised. 

Tapping  as  a  palliative  procedure  should  never  be  per- 
formed. The  dangers  that  may  result  from  the  tapping 
cannot  be  disregarded,  and  no  hope  whatever  of  cure  can 


TREATMENT  OF  OVARIAN  CYSTS.  385 

be  held  out  to  the  patient.  When  operation  is  finally- 
performed,  it  is  rendered  much  more  difficult  from  the 
adhesions  that  have  resulted  from  previous  tappings. 

Operation. — The  treatment  of  ovarian  cysts  is  opera- 
tive. Celiotomy  should  be  performed  and  the  tumor  re- 
moved without  delay.  The  dangers  due  to  the  accidents 
that  may  occur  show  the  risk  of  waiting  after  a  diagnosis 
has  been  made.  When  the  tumor  is  small  the  operative 
complications  and  dangers  are  at  a  minimum. 

Even  if  the  tumor  be  discovered  accidentally  by  the 
physician,  and  has  never  given  any  trouble  to  the  wom- 
an, operation  for  its  removal  should  be  advised.  A  der- 
moid that  has  existed  for  years  may  suddenly  endanger 
the  woman's  life.  Delay  in  the  case  of  papillomatous 
tumors — and  no  one  can  determine  in  the  early  stages 
whether  or  not  a  cyst  be  papillomatous — is  especially 
dangerous.  About  one-half  the  women  upon  whom  I 
have  operated  for  papillomatous  cysts  have  come  to  me 
after  the  peritoneum  had  become  infected.  Though  the 
peritoneum  be  extensively  involved,  operation  is  by  no 
means  hopeless.  As  in  the  case  of  tuberculosis  of  the 
peritoneum,  so  in  papilloma,  the  opening  and  draining 
of  the  abdominal  cavity  may  result  in  cure. 

Pregnancy  is  no  contraindication  to  operation.  In  fact, 
the  dangers  of  obstructed  labor,  of  rupture  of  the  cyst, 
and  of  torsion  of  the  pedicle  urgently  call  for  immediate 
operation  in  such  cases.  Pregnancy  usually  progresses  to 
full  term  after  operation. 

25 


CHAPTER   XXXII. 
SOLID  TUMORS  OF  THE  OVARY. 

Solid  tumors  of  the  ovary  are  of  rare  occurrence. 
They  are  said  to  be  found  in  about  5  per  cent,  of  all  the 
cases  of  ovarian  tumors  that  are  submitted  to  operation. 

The  solid  tumors  of  the  ovary  are  fibromata,  myom- 
ata,  sarcomata,  carcinomata,  and  papillomata. 

Fibromata. — Ovarian  fibromata  are  very  rare;  they  are 
histologically  similar  to  fibroid  tumors  of  other  parts  of 
the  body.  They  do  not  form  circumscribed  new  growths, 
but  affect  the  whole  organ,  which  becomes  uniformly  hy- 
pertrophied,  preserving  its  general  shape  and  anatomical 
relations.  The  tumor  may  contain,  between  the  bundles 
of  fibrous  tissue,  small  cavities  filled  with  fluid.  The 
growth  is  usually  intra-peritoneal  and  has  a  well-formed 
pedicle;  it  may,  however,  in  exceptional  cases  be  extra- 
peritoneal and  develop  between  the  layers  of  the  broad 
ligament.  In  such  a  case  there  is  difficulty  in  determin- 
ino^  whether  the  fibroid  originated  in  the  uterus  or  in  the 
ovary.  Ovarian  fibromata  are  usually  of  small  size  and 
slow  growth.  A  case  has  been  reported  in  which  the 
tumor  weighed  over  7  pounds. 

Corpora  Fibrosa. — A  variety  of  the  ovarian  fibromata 
are  the  corpora  fibrosa,  which  are  due  to  fibroid  degenera- 
tion of  the  corpus  luteum.  They  are  tough,  fibrous 
bodies,  about  the  size  of  a  pea,  which  are  occasionally 
found  upon  the  surface  of  the  ovary.  It  is  said  that  they 
may  attain  the  size  of  a  child's  head.  They  are  usually, 
however,  very  small,  and  have  no  clinical  significance. 

Myomata. — Ovarian  myomata  are  composed  chiefly 
of  unstriped  muscular  fiber.  They  are  somewhat  more 
frequent  than  the  pure  fibromata.     The  two  growths  may 


SOLID  TUMORS  OF  THE  OVARY.  387 

be  mixed,  forming  a  fibro-myomatous  tumor.  The  my- 
omatous tumor  may  attain  the  weight  of  fifteen  pounds. 

Sarcomata. — The  majority  of  solid  tumors  of  the 
ovary  are  sarcomatous  in  character,  and  it  seems  prob- 
able that  many  tumors  that  are  classed  as  fibroids  or 
fibro-myomata  are  in  reality  ovarian  sarcomata.  The 
growth  may  be  either  of  the  spindle-cell  or  the  round- 
cell  variety.  Occasionally  it  is  an  endothelioma,  a  form 
of  sarcoma  developing  from  the  endothelial  cells  of  the 
blood-  and  lymph-vessels. 

Sarcoma  of  the  ovary  differs  from  sarcoma  in  other 
parts  of  the  body  in  the  fact  that  it  is  very  often  bilateral. 
Sutton  states  that  both  ovaries  are  affected  in  about  20 
per  cent,  of  the  cases.  Other  observers  state  that  ova- 
rian sarcomata  are  usually  bilateral. 

The  surface  of  the  tumor  is  smooth,  and  the  general 
form  and  anatomical  relations  of  the  ovary  are  unaltered. 
Ovarian  sarcomata  are  usually  of  median  size,  though 
they  may  attain  enormous  proportions  and  fill  the  ab- 
dominal cavity. 

The  tumor  is  usually  of  rapid  growth;  in  one  case  it 
attained  a  weight  of  ten  pounds  within  a  period  of  six 
months.  The  growth  is  accelerated  by  pregnancy.  As- 
cites is  commonly  present  with  ovarian  sarcoma,  and 
cachexia  may  appear  rapidly. 

Ascites  caused  by  peritoneal  irritation  may  accom- 
pany any  of  the  solid  tumors  of  the  ovary,  as  other 
kinds  of  freely  movable  abdominal  tumor.  It  is,  how- 
ever, especially  characteristic  of  the  ovarian  sarcomata, 
and  is  a  point  of  diagnostic  importance. 

Ovarian  sarcomata  differ  from  the  fibroid  and  the  myom- 
atous tumors  in  rapidity  of  growth,  involvement  of  both 
ovaries,  and  the  presence  of  ascites.  Ovarian  sarcomata 
may  occur  at  any  age.  They  are  relatively  very  frequent 
in  children.  An  analysis  of  60  cases  of  ovarian  tumors 
in  children  collected  by  Sutton  shows  that  sarcomata  oc- 
curred 16  times. 

The  symptoms  caused  by  ovarian  fibromata,  myomata. 


388     A   TEXT-BOOK  OF  DISEASES  OF  WOM'eN. 

and  sarcoma  are  those  referable  to  pressure  and  peri- 
toneal irritation.  These  tumors,  on  account  of  their 
moderate  size  and  great  mobility,  seem  to  be  especially 
liable  to  torsion  of  the  pedicle.  They  should  be  removed 
by  celiotomy  as  soon  as  recognized. 

Both  ovaries  should  always  be  carefully  examined,  for 
in  sarcoma  the  disease  is  often  bilateral. 

Carcinomata. — Primary  cancer  of  the  ovaries  is  very 
rare.  Secondary  infection  of  these  organs  is,  hov^^ever, 
of  not  infrequent  occurrence.  It  is  found  in  cases  of 
cancer  of  the  breast  and  of  the  uterus.  In  29  cases  of 
death  from  cancer  of  the  breast,  both  ovaries  were  found 
to  be  involved  in  3  cases. 

Primary  cancer  of  the  ovary  appears  as  a  solid  or  a 
cystic  tumor.  The  solid  carcinomata  are  diffuse  infiltra- 
tions of  the  ovarian  tissue,  forming  pedunculated,  rarely 
intraligamentous,  ovoid  or  globular  tumors  having  a 
smooth  or  slightly  irregular  surface.  They  are  either  of 
the  medullary  or  scirrhous  type.  The  medullary  form  is 
of  rapid  growth,  and  may  reach  the  size  of  the  adult  head. 
The  scirrhous  form  is  of  comparatively  slow  growth  and 
smaller  size,  and  in  consistency  resembles  a  fibroma. 

The  cystic  carcinomata  are  similar  in  form  to  the  mul- 
tilocular  glandular  cysts,  but  are  smaller,  rarely  reaching 
a  greater  size  than  that  of  the  adult  head.  They  are 
adeno-carcinomata  or  papillary  adeno-carcinomata.  The 
surface  of  the  tumor,  its  walls,  and  the  septa  contain  to 
a  greater  or  less  extent  solid  nodules  or  plates  of  various 
size  composed  of  carcinomatous  tissue.  The  nodules 
often  have  a  papillary  character. 

Ovarian  carcinoma  is  usually  a  bilateral  growth.  Un- 
like carcinoma  in  other  parts  of  the  body,  it  may,  partic- 
ularly the  medullary  form,  occur  in  childhood.  It  is 
usually  found  between  the  ages  of  thirty  and  sixty  years. 
Ascites  is  commonly  present  in  cancer  of  the  ovaries,  the 
fluid  being  often  tinged  with  blood  ;  as  the  disease  devel- 
ops, edema  of  the  lower  limbs  and  cachexia  appear. 

Cancer  of  the  ovary  is  an  extremely  malignant  growth, 


SOLID  TUMORS  OF  THE  OVARY.  389 

quickly  extending  to  surrounding  structures  as  implan- 
tations on  the  peritoneum,  and  by  metastasis  to  distant 
organs.  In  more  than  75  per  cent,  of  the  cases  operated 
upon  the  disease  has  returned  and  terminated  in  death 
within  the  first  year. 

When  cancer  of  the  ovaries  is  secondary  to  cancer  else- 
where than  in  the  uterus,  operation  offers  no  prospect  of 
cure.  If  the  disease  is  secondary  to  cancer  of  the  uterus, 
it  may  be  possible  to  remove  all  of  the  affected  structures. 

Ovarian  Papillotnata. — Superficial  papillomata  of  the 
ovary  are  of  very  rare  occurrence.  In  many  of  the  cases 
in  which  the  papillomata  appear  to  grow  from  the  surface 
of  the  ovary  there  had  previously  been  a  papillomatous 
cyst  of  paroophoritic  origin,  which  had  become  perforated 
and  perhaps  inverted,  so  that,  after  the  cyst  had  become 
destroyed,  the  growths  appeared  to  spring  from  the  ova- 
rian surface.  Careful  dissection  and  search  for  the  re- 
mains of  the  old  cyst  should  always  be  made  in  such 
cases. 

In  superficial  papilloma  of  the  ovary  the  growths  are 
in  all  respects  similar  to  those  found  in  the  interior  of 
papillomatous  cysts.  They  may  be  isolated  upon  the 
surface  of  the  ovary,  or  they  may  cover  it  so  completely 
that  the  ovary  is  hidden  from  view.  A  section,  however, 
will  reveal  the  ovary  lying  in  the  centre  of  the  growth. 

The  papillomata  may  be  pedunculated  or  sessile.  They 
vary  in  size.  In  some  cases  they  form  a  mass  larger  than 
the  adult  fist. 

The  disease  is  often  bilateral.  Secondary  involvement 
of  the  peritoneum  occurs,  as  in  the  case  of  papillomatous 
cyst.  The  course  of  the  disease  is  similar  to  that  of  a 
perforated  papillomatous  cyst.  The  treatment  is  im- 
mediate celiotomy  and  removal.  As  in  the  case  of 
papillomatous  cysts,  involvement  of  the  peritoneum  is 
no  contraindication  to  operation. 

Tuberculosis  of  the  Ovary. — Tuberculosis  of  the 
ovary  is  usually  secondary  to  tuberculosis  of  the  Fallo- 
pian tubes.    In  tuberculosis  of  the  peritoneum  the  ovaries 


390      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN, 

are  often  found  to  be  involved,  in  some  cases  without  ac- 
companying disease  of  the  tube.  In  phthisical  women 
the  ovaries  have  been  found,  in  rare  instances,  to  be  the 
only  portion  of  the  genital  apparatus  in  which  secondary 
deposit  of  tubercles  took  place. 

Williams  states  that  primary  tuberculosis  of  the  ovaries 
has  not  yet  been  described. 

The  surface  of  the  ovary  may  be  covered  with  miliary 
tubercles,  or  they  may  be  scattered  through  the  substance 
of  the  gland.  In  other  cases  the  ovary  contains  cavities 
filled  with  cheesy  material  or  pus,  forming  a  tuberculous 
abscess. 

There  are  no  characteristic  symptoms  of  tuberculosis 
of  the  ovaries.  The  condition  is  usually  found  at  ope- 
ration or  at  autopsy,  associated  with  tuberculosis  of  the 
peritoneum  or  of  some  other  part  of  the  genital  organs, 
as  the  Fallopian  tubes  and  the  uterus. 

The  treatment  consists  in  oophorectomy,  unless  opera- 
tion is  contraindicated  on  account  of  extensive  involve- 
ment of  other  structures. 

Tumors  of  the  Ovarian  I/igament. — Fibroid  and 
sarcomatous  tumors  have  occasionally  been  found  in  the 
ovarian  ligament.  Doran  has  reported  a  fibroid  of  the 
ovarian  ligament  that  weighed  17  pounds.  The  writer 
has  removed  a  sarcoma  of  the  ovarian  ligament  that 
weighed  5  pounds. 

It  is  impossible  to  distinguish  these  tumors  from  similar 
growths  of  the  ovary.     They  demand  like  treatment. 


CHAPTER   XXXIII. 
MALFORMATIONS  OF  THE  GENITAL  ORGANS. 

Congenital  malformations  are  found  in  all  parts  of 
the  genital  tract.  Some  of  the  more  common  forms,  like 
arrested  development  of  the  uterus,  have  been  referred  to 
in  the  previous  pages.  Others  will  briefly  be  considered 
here.  Reference  to  the  method  of  development  of  the 
sexual  organs  will  elucidate  this  subject. 

The  Fallopian  tubes,  the  uterus,  and  the  vagina  are 
developed  from  two  embryonic  structures  called  the  ducts 
of  Miiller.  These  ducts  become  fused,  first  at  the  lower 
extremity,  between  the  sixth  and  eighth  weeks  of  fetal 
life  (Fig.    175).     The  early  genital  tract  thus  formed  is 


Fig.   175 — Diagrams  showing   the  development  of  the  vagina  and  the  uterus 
from  Miiller's  ducts. 

consequently  divided  throughout  by  a  septum,  which 
normally  disappears  during  fetal  development,  so  that 
there  results  one  vaginal  and  uterine  tract,  from  which 
the  Fallopian  tubes  branch. 

The  most  important  malformations  of  the  vagina  and 

391 


392      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

the  uterus  arise  from  arrest,  at  any  stage,  of  this  normal 
developmental  process. 

Very  rarely  the  uterus  is  completely  absent,  or  it  may 
be  represented  by  a  small  band  of  muscular  and  connec- 
tive tissue  stretched  across  the  pelvis.  In  other  cases  the 
cervix  is  well  formed,  while  the  body  of  the  uterus  is  but 
poorly  developed. 

We  have  seen  that  this  condition  is  often  associated  with 
pathological  anteflexion  of  the  uterus. 

Uterus  Unicornis. — Sometimes  there  is  arrest  in  the 
development  of  one  of  IMiiller's  ducts,  so  that  the  uterus 
becomes  one-sided  or  one-horned  and  presents  only  one 
formed  Fallopian  tube.  In  such  a  case  both  ovaries  may 
be  present. 

Uterus  Didelphys. — :\Iiiller's  ducts  may  unite  only  as 
far  as  the  top  of  the  vagina,  no  fusion  whatever  taking 
place  in  the  uterine  portion.     In  such  a  case  two  sepa- 


FiG.  176. — Uterus  didelphys  and  double  vagina. 


rated  uterine  bodies  are  produced;  the  condition  of  double 
uterus  exists  (Fig.  176). 

Uterus  Bicornis  Duplex. — In  this  variety  of  malfor- 
mation development  has  preceded  a  step  farther  than  in  the 


MALFORMA  TIONS  OF  THE  GENITAL  ORGANS.     393 

preceding  variety.  The  uterine  bodies  have  become  ex- 
ternally united.  There  is,  however,  no  fusion  of  the 
cavities.  Two  cavities  are  present,  opening  into  a  double 
vagina. 

Uterus  Bicornis  Unicollis. — Here  the  development 
of  the  cervix  and  the  lower  part  of  the  uterus  is  normal. 
The  upper  parts  of  the  body  of  the  uterus  have  not  be- 
come fused,  and  diverge  sharply  from  each  other.  The 
organ  is  two-horned  (Fig.    177). 


Fig.  177. — Uterus  bicornis  unicollis  (Winckel). 

Uterus  Cordifonnis. — In  this  variety  the  two  halves 
of  the  uterus  are  united  throughout.  Externally  on  the 
fundus  there  appears  a  slight  depression,  which,  with  the 
broad  body  of  the  uterus,  demonstrates  the  imperfection 
of  development.  The  name  is  derived  from  the  resem- 
blance to  the  conventional  heart-shape. 

Uterus  Septus. — In  this  variety  development  has  pro- 
■gressed  so  far  that  externally  the  uterus  presents  the  nor- 
mal appearance.  The  septum  that  divides  the  two  ducts 
has,  however,  failed  to  disappear,  and  a  divided  uterus 
results.  The  septum  may  extend  throughout  the  body 
.of  the  uterus,  or  it  may  be  less  perfectly  formed.  Often 
.one  side  of  the  uterus  is  better  developed  than  the  other 
.(Fig.  178). 

Malformation  of  the  Vagina. — Malformation  of  the 
vagina  is  frequently  present  with  malformation  of  the  ute- 
rus. The  septum  that  divides  Miiller's  ducts  may  per- 
sist throughout  the  whole  length  of  the  vagina,  forming 
.a  double  vagina;  or  the  septum   may  have  partly   dis- 


394     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

appeared,  being  present  in  various  stages  of  perfection. 
In  double  vagina  each  orifice  may  be  guarded  by  a  dis- 
tinct hymen. 

Sometimes  one  of   the  canals  of  a  double  vagina  is 
much  better  developed  than  the  other.     The  orifice  of 


Fig.  178. — Uterus  septus  (Cruveilhier). 

the  poorly  developed  canal  may  be  closed  at  its  lower 
extremity,  so  that  the  malformation  is  never  recognized 
by  the  woman  or  physician  unless  the  closed  canal  be- 
come distended  with  blood  or  other  secretion.  A  variety 
of  vaginal  cyst  may  be  formed  in  this  way. 

Unilateral  Vagina. — In  this  variety  of  malformation 
one  of  the  ducts  of  Miiller  fails  to  develop  at  all.  The 
condition  always  occurs  with  uterus  unicornis.  The 
vaginal  canal  is  smaller  than  normal  and  may  be  situated 
to  one  side  of  the  median  line. 

Absence  of  the  vagina  rarely  occurs.  There  may  be  no 
sign  whatever  of  this  structure,  or  it  may  be  represented 
by  a  fibrous  cord.  The  external  genitals  may  also  be 
absent,  or  they  may  be  well  developed. 

If  the  uterus  and  ovaries  are  well  developed,  much 
trouble  may   arise    from    retention   of   menstrual  blood. 

An  attempt  should  be  made,  by  means  of  a  transverse 
incision  between  the  rectum  and  the  urethra,  to  reach  the 
cervix,  and,  if  possible,  to  make  an  artificial  vagina  by 


MALFORMA  TIONS  OF  THE  GENITAL  ORGANS.     395 


Fig.  179. — Transverse  septum  of 
the  vagina  (Heyder). 


transposition  of  skin  from  the  buttocks.  Such  treatment 
is  usually  unsatisfactory,  as  a  patulous  canal  cannot  be 
maintained.  It  may  be  necessary  to  remove  the  uterus 
and  appendages. 

Sometimes  the  vagina  is  absent  in  only  part  of  its 
course,  being  open  below  and 
represented  above  by  a  fibrous 
cord;  or  the  upper  and  lower 
portions  may  be  developed, 
while  the  middle  portion  is 
imperforate. 

These  conditions  are  more 
amenable  to  operative  treat- 
ment than  in  the  case  of  com- 
plete absence  of  the  vagina. 
The  intervening  septum  should 
be  incised,  and  the  patulous 
condition  maintained  by  the 
passage  of  bougies  if  necessary. 

Sometimes  the  lumen  of  the  vagina  is  obstructed  by 
the  presence  of  transverse  bands  or  crescentic  folds,  which 
have  been  described  as  supplementary  hymens  (Fig.  179). 
A  hematocolpos  is  produced  when  the  vagina  becomes  dis- 
tended with  menstrual  blood  above  such  an  obstruction. 

Hermaphroditism. — A  true  hermaphrodite  is  an  indi- 
vidual who  possesses  the  organs  of  both  sexes  in  a  condi- 
tion of  perfect  function.  The  existence  of  true  hermaph- 
roditism is  denied  by  many  authorities  of  the  present 
day,  though  the  older  writers  firmly  believed  in  it.  It  is 
doubtful  if  there  are  any  cases,  recorded  as  true  hermaph- 
rodites, in  which  the  demonstration  of  the  condition 
is  not  open  to  serious  criticism;  such  individuals  are  in 
reality  pseudo-hermaphrodites. 

A  pseudo-hermaphrodite  is  possessed  of  a  distinct  sex, 
and  has  either  ovaries  or  testicles,  though  the  external 
o-enitals  and  other  secondary  sexual  characteristics  may 
present  the  appearance  of  a  double  sex. 

In    male  pseiido-hermaphroditism   the    individual   has 


396      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

testicles,  and  the  external  genital  organs  simulate  those 
of  the  female. 

In  female  pseiido-hennaphroditisin  the  individual  has 
ovaries,  and  the  external  genital  organs  simulate  those 
of  the  male. 

In  male  pseudo-hermaphroditism  the  condition  of 
hypospadias  is  usually  present,  the  lower  surface  of  the 
urethra  and  the  perineum  being  split.  The  penis  may 
be  very  small  and  imperforate,  the  urethra  opening  at  its 
base.  The  fissure  of  the  perineum  closely  resembles  the 
vagina,  and  the  split  scrotum  may  be  mistaken  for  the 
labia.  Cases  of  this  kind  are  on  record  in  which  the  in- 
dividuals, ignorant  of  their  true  sex,  have  for  years  in- 
dulged in  sexual  connection  with  men. 

In  female  pseudo-hermaphroditism  there  is  hypertrophy 
of  the  clitoris  and  the  prepuce,  with  approximation  of  the 
labia  majora  and  contraction  or  occlusion  of  the  ostium 
vaginae,  giving  the  genitals  the  appearance  of  the  mascu- 
line type. 

The  secondary  sexual  characteristics  of  both  varieties 
of  pseudo-hermaphrodites — the  distribution  of  hair, 
mammary  development,  shape,  voice,  etc. — are  usually 
of  the  feminine  t}-pe. 

It  is  often  exceedingly  difficult  to  determine  during  life 
the  true  sex  of  the  individual  in  cases  of  hermaphro- 
ditism. 

The  labia  should  be  carefully  palpated  to  determine 
whether  or  not  testicles  are  present.  Rectal  examination 
should  be  made  to  determine  the  existence  of  uterus  or 
ovaries.  The  sexual  inclinations  of  the  individual  should 
be  observed.  The  discharge  from  the  genitals  during 
sexual  excitement  should  be  examined  for  spermatozoa. 

If  conception  occurs,  of  course  all  doubt  is  removed. 
If  the  sex  cannot  be  definitely  determined  by  such  exam- 
ination, it  is  best  to  consider  the  case  one  of  male  pseudo- 
hermaphroditism, which  is  the  usual  form,  and  to  treat 
the  individual  as  a  male. 


CHAPTER   XXXIV. 
DISORDERS   OF   MENSTRUATION. 

Menstruation,  or  the  regular  periodical  discharge  of 
blood  from  the  uterus,  is  a  phenomenon  that  occurs  only 
in  the  human  race  and  in  some  monkeys.  The  anatomi- 
cal changes  that  accompany  menstruation  have  not  yet 
been  definitely  determined.  Nothing  is  known  with  any 
degree  of  certainty  regarding  its  cause  and  significance. 
There  is  much  diversity  of  opinion  in  regard  to  the  coin- 
cidence of  ovulation  and  menstruation.  Ovulation  and 
conception  may  occur  when  menstruation  is  absent,  and 
it  seems  probable  that  menstruation  may  take  place  in- 
dependently of  ovulation. 

The  process  of  menstruation  is  in  many  respects  differ- 
ent from  the  rut  of  other  animals. 

Menstruation  usually  begins  in  this  country  at  the 
fourteenth  year.  The  time  of  the  first  appearance  of  the 
process  is  influenced  by  race,  climate,  and  environment. 
As  a  rule,  it  begins  earlier  in  warm  climates  and  later  in 
cold  climates.  It  is  earlier  in  girls  who  lead  luxurious, 
indolent  lives  than  in  girls  of  the  working  classes. 

Precocious  menstruation  rarely  occurs  at  a  very  early 
age.  It  has  been  known  to  begin,  and  to  recur  with 
regularity,  from  the  time  of  birth.  In  such  cases  there 
is  a  corresponding  premature  development  of  the  sexual 
organs. 

The  fuenstriial  fltiid  consists  of  blood,  mucous  secre- 
tion from  the  uterus  and  vagina,  and  epithelial  cells  from 
the  endometrium. 

The  normal  duration  of  the  flow  is  from  two  days  to  a 
week.  The  amount  of  fluid  discharged  is  from  2  to  9 
ounces.     Menstruation  occurs   every  twenty-eight  days, 

397 


398      A    TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

counting  from  the  beginning  of  one  period  to  the  begin- 
ning of  another.  The  menstrual  interval  is  subject  to 
considerable  individual  variations,  which  appear  to  be 
within  the  limits  of  health.  It  sometimes  occurs  with 
regularity  every  two,  three,  or  five  weeks.  When  it 
occurs  every  two  weeks,  the  alternate  flows  are  often 
but  small  in  amount.  The  occurrence  of,  or  the  attempt 
at,  menstruation  every  two  weeks,  in  a  woman  who  had 
previously  menstruated  monthly,  is  sometimes  a  symp- 
tom of  beginning  uterine  disease. 

Menstruation  commonly  ceases  at  about  the  forty-fifth 
year,  when  the  menopause  appears. 

Most  of  the  disorders  of  menstruation  have  already 
been  considered  as  symptoms  of  the  various  lesions  of 
the  genital  organs  that  have  been  described  in  the  pre- 
vious pages. 

There  are  some  disorders  of  menstruation,  however, 
often  unaccompanied  by  discoverable  lesions,  which  now 
demand  consideration. 

Amenorrhea. — Amenorrhea  is  the  absence  of  men- 
struation. Failure  of  the  menstrual  blood  to  be  dis- 
charged from  the  vagina,  such  as  occurs  in  cases  of 
atresia,  is  not  necessarily  amenorrhea;  menstruation  may 
have  taken  place,  though  the  most  marked  phenomenon 
of  this  process,  the  discharge  of  blood,  is  concealed. 

The  term  primary  amenorrhea,  or  eynmisio  inensiiim^ 
is  applied  to  those  cases  in  which  menstruation  has  never 
appeared.  Secondary  amenorrhea,  or  suppressio  men- 
shim^  is  applied  to  those  cases  in  which  menstruation  has 
ceased  after  having  once  been  established. 

Amenorrhea  is  due  to  defective  development  of  the 
organs  of  generation;  to  premature  atrophy,  such  as 
occurs  in  superinvolution  of  the  uterus;  to  lesions, 
pathological  and  traumatic;  to  acute  and  chronic  general 
diseases;  and  to  psychical  disturbances. 

Menstruation  is  often  absent  during  the  acute  diseases, 
such  as  typhoid  fever,  and  it  may  remain  suppressed 
until  the  general  health  is  fully  restored. 


DISORDERS  OF  MENSTRUA  TION.  399 

Amenorrhea  may  also  occur  in  any  chronic  debilitating 
condition.  It  is  common  in  chlorosis,  anemia,  phthisis, 
and  malaria. 

It  frequently  results  from  changes  of  climate  and  sur- 
roundings, and  continues  until  the  person  becomes 
adapted  to  the  new  environment.  It  is  seen  in  emi- 
grants from  other  countries,  and  in  women  who  move 
from  the  country  to  large  cities.  It  is  often  caused  by 
overwork,  physical  and  mental,  and  by  insufficient  food. 
It  is  not  uncommon  in  studious  school-girls. 

Amenorrhea  is  sometimes  due  to  the  excessive  general 
development  of  fat,  even  in  young  woman  who  are  ap- 
parently in  good  general  health. 

Amenorrhea  is  frequently  associated  with  insanity.  It 
may  be  caused  by  fright,  grief,  or  anxiety.  The  fear  of 
pregnancy  after  illicit  coitus  sometimes  produces  it 

In  some  unusual  cases  amenorrhea  is  present  without 
any  discoverable  cause.  The  woman  may  be  in  perfect 
general  health,  and  the  sexual  organs  may  be  well  devel- 
oped, at  least  so  far  as  can  be  determined  by  physical 
examination. 

In  amenorrhea  there  is  often  a  general  periodical  dis- 
turbance that  marks  the  times  at  which  the  menstrual 
bleeding  should  occur.  There  may  be  headache,  flashes 
of  heat,  nervousness,  nausea  and  vomiting,  and  a  feeling 
of  fulness  and  pain  in  the  pelvis.  Various  cutaneous 
eruptions  may  occur  as  the  result  of  amenorrhea,  as  in 
other  diseases  of  the  genital  apparatus. 

The  poor  health,  mental  and  physical,  that  usually  ac- 
companies amenorrhea  is  often  thought  by  the  patient 
and  her  friends  to  be  the  result,  rather  than  the  cause — 
as  it  really  is — of  the  arrested  bleeding. 

Treatment. — The  treatment  of  amenorrhea  depends 
upon  the  cause  of  the  condition.  Little,  if  any,  benefit 
is  to  be  expected  in  those  cases  due  to  defective  develop- 
ment of  the  uterus  or  the  ovaries.  If  an  attempt  at  men- 
struation is  made,  as  shown  by  periodical  local  pain  and 
general  disturbance,  and  the  uterus  is  found  to  be  small 


400     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

and  sharply  anteflexed,  benefit  may  sometimes  result  from 
thorough  dilatation  of  the  cervix. 

Most  cases  of  amenorrhea  demand  general  treatment. 
The  mode  of  life  should  be  regulated  according  to  strict 
hygienic  principles.  Fresh  air,  sunshine,  baths,  and 
suitable  exercise  should  be  prescribed.  Studious  girls 
should  be  made  to  lead  more  active  lives.  A  change  of 
surroundings  is  beneficial.  A  visit  to  the  seashore  and 
salt-water  baths  are  of  advantage. 

The  general  health  should  be  improved  by  the  admin- 
istration of  iron,  strychnine,  or  some  other  tonic.  Bland's 
pill  and  the  hypophosphites  are  useful.  Obesity  should 
be  relieved  by  a  regulated  diet  and  exercise.  The  regu- 
larity of  the  bowels  should  always  be  carefully  attended 
to.  Most  of  the  so-called  emmenagogues  are  of  but  little, 
if  any,  value.  Benefit  is  sometimes  derived  from  the  use 
of  potassium  permanganate  (gr.  j-ij  three  times  a  day) 
and  the  binoxide  of  manganese  (gr.  j-ij  three  times  a 
day).  These  medicines  should  be  administered  in  pill 
form  for  several  weeks. 

Oxalic  acid  in  doses  of  from  yV  to  ^  of  a  grain,  given 
in  lemon  syrup  for  a  period  of  from  one  to  four  months, 
has  been  recommended,  and  is  sometimes  very  useful. 

It  seems  probable  that  pelvic  massage  practised  for  a 
period  of  several  months  may  result  in  benefit. 

Acute  suppression  of  menstruation  during  a  men- 
strual period  is  a  phenomenon  to  which  the  term  amen- 
orrhea is  not  properly  applicable.  It  may  be  caused  by 
exposure  to  cold  or  by  some  sudden  emotional  disturbance 
during  the  menstrual  flow. 

The  condition  may  be  unaccompanied  by  any  subjec- 
tive symptoms,  or  there  may  be  present  ovarian  and  pel- 
vic pain. 

The  treatment  consists  in  rest  in  bed,  the  application 
of  warm  fomentations  to  the  lower  abdomen,  and  hot 
foot-baths.  Especial  care  of  the  general  health  should 
be  observed  at  the  following  menstrual  period. 

Scanty  Menstruation. — Scanty  menstruation  occurs 


DISORDERS  OF  MENS  TR  UA  TION.  40 1 

when  the  menstrual  flow  is  much  less  than  normal.  It 
must  be  remembered  that  individual  peculiarities  in  this 
respect  may  be  within  the  limits  of  health.  When  one 
or  more  periods  are  missed,  and  the  flow  shows  a  contin- 
ual tendency  to  diminish  in  amount,  treatment  may  be 
demanded. 

The  causes  and  the  treatment  of  scanty  menstruation 
are  those  which  have  already  been  considered  under 
Amenorrhea. 

Vicarious  Menstruation. — Vicarious  menstruation  is 
the  discharge  of  blood,  at  the  menstrual  periods,  from 
some  part  of  the  body  other  than  the  uterus.  In  some 
cases,  instead  of  a  discharge  of  blood,  a  secretion  of  an- 
other character  takes  place. 

The  vicarious  discharge  may  be  the  only  phenomenon 
present,  or  it  may  occur  supplementary  to  the  normal 
uterine  bleeding. 

The  vicarious  bleeding  may  take  place  from  almost  any 
part  of  the  mucous  or  cutaneous  structures.  It  occurs 
from  the  nose,  the  throat,  the  lungs,  the  stomach,  the 
bladder,  and  the  anus.  It  may  occur  from  an  ulcer  or 
other  lesion  of  the  external  surface.  Sometimes  the  cu- 
taneous hemorrhages  appear  in  the  form  of  ecchymoses. 

Various  secretions  may  take  the  place  of  the  bleeding. 
A  monthly  flow  of  milk  from  the  breasts  has  been  ob- 
served, and  a  periodical  diarrhea  or  leucorrhea  has  taken 
place. 

Vicarious  menstruation  is  a  rare  condition.  It  may 
occur  in  defective  development  of  the  uterus  and  ovaries. 
It  is  usually  found  in  debilitated  nervous  women,  and  ac- 
companies a  deficient  menstrual  discharge  from  the 
uterus. 

Treatment. — Direct  local  treatment  should  be  applied 
to  the  vicarious  bleeding  only  when  it  becomes  excessive. 
The  general  health  of  the  woman  should  receive  atten- 
tion. Treatment  should  be  applied  to  any  local  lesion  of 
the  genital  apparatus  that  may  be  discovered.  The  direc- 
tions given  for  amenorrhea  are  also  applicable  here, 

26 


CHAPTER   XXXV. 
THE    MENOPAUSE. 

The  menopause,  or  the  final  cessation  of  menstruation, 
occurs  between  the  fortieth  and  fiftieth  years,  usually 
about  the  age  of  forty-five. 

The  menstrual  bleeding  may  gradually  diminish  in 
amount  until  it  disappears;  or  it  may  stop  abruptly  and 
permanently;  or  there  may  occur  one  or  more  intervals 
of  amenorrhea  of  one,  two,  or  three  months'  duration, 
followed  by  normal  menstrual  bleedings,  perhaps  of 
diminished  amount,  before  the  flow  finally  ceases. 

Profuse  bleeding  at  the  time  of  the  menopause  and 
slight  bleeding  occurring  more  often  than  monthly 
are,  unfortunately,  viewed  by  most  women  as  of  no 
moment,  and  as  part  of  the  normal  phenomena  of 
the  change  through  which  they  are  passing.  The  same 
may  be  said  of  the  apparent  reappearance  of  menstrua- 
tion, or  of  slight  irregular  hemorrhages  occurring  after 
the  menopause  had  been  established  and  menstruation  had 
been  absent  perhaps  for  many  months.  These  phenom- 
ena are  not  normal.  They  should  always  excite  the 
alarm  of  the  woman,  and  they  demand  immediate  exami- 
nation on  the  part  of  her  physician.  As  a  rule,  the  bleed- 
ing is  caused  by  some  pathological  condition  of  the  ute- 
rus— fungous  growths,  polypi,  fibroids,  or  cancer.  The 
benign  lesions  may  disappear  spontaneously  with  the 
progressing  atrophy  of  the  womb,  and  the  hemorrhages 
may  cease.  Many  women  undoubtedly  recover  without 
treatment,  and  are  thus  confirmed  in  the  belief  that  such 
irregular  hemorrhages  are  a  normal  part  of  the  meno- 
pause ;  and  the  unfortunate  women  with  cancer  are  thus 

402 


THE  MENOPAUSE.  403 

encouraged  to  delay  seeking  medical  advice  until  the  dis- 
ease has  progressed  too  far  for  cure. 

The  normal  changes  of  the  genital  organs  that  occur 
at  the  menopause  are  atrophic  in  character. 

If  the  woman  is  in  good  general  health,  and  has  no 
disease  of  the  uterus,  the  tubes,  or  the  ovaries,  the  meno- 
pause may  become  established  without  any  marked  gen- 
eral disturbance. 

In  many  cases,  however,  very  annoying  general  symp- 
toms appear,  and  last  for  one  or  two  years  before  the 
woman  becomes  adapted  to  the  altered  conditions. 

There  may  be  headache,  flushes  of  heat,  nervous  de- 
pression, derangement  of  the  digestive  apparatus,  and 
other  functional  disturbance.  The  woman  often  becomes 
very  fat  at  this  period.  The  nervous  derangement  may 
be  so  severe  as  to  result  in  insanity. 

The  vaso-motor  disturbances  are  often  the  most  annoy- 
ing. The  phenomena  of  the  ' '  flushes ' '  consist  of  a  feel- 
ing of  heat  over  the  whole  or  a  part  of  the  body,  followed 
by  sweating  and  the  sensation  of  cold  or  a  slight  chill. 
The  flushes  may  occur  frequently  during  the  day,  some- 
times several  times  during  an  hour. 

The  treatment  of  the  menopause  should  be  directed  to 
the  maintenance  of  the  general  bodily  and  mental  health. 
The  diet  should  be  carefully  regulated.  Too  much 
nutritious  food  should  be  forbidden.  Purgatives  should 
be  administered  whenever  necessary.  The  woman  should 
have  plenty  of  fresh  air  and  the  proper  amount  of  exer- 
cise. Mental  depression  demands  a  change  of  locality 
and  surroundings. 


CHAPTER   XXXVI. 

GENITAL   FISTUL/E. 

Fistulous  openings  may  exist  between  the  different 
portions  of  the  genital  tract  and  the  neighboring  struc- 
tures. Such  fistulse  are  the  result  of  childbirth,  opera- 
tive or  other  form  of  traumatism,  congenital  defect,  can- 
cer, syphilis,  or  suppuration.  The  accompanying  diagram 
(Fig.  i8o)  shows  the  chief  varieties  of  fistula  that  occur. 


Fig.  i8o. — Diagram  illustrating  the  chief  varieties  of  genital  fistula:  v.  u., 
vesico-uterine  fistula;  v.  v.,  vesico-vaginal  fistula;  u.  z-.,  urethro-vaginal  fistula; 
r.  v.,  recto-vaginal  fistula. 

Vesico-vaginal  Fistula.— The  most  frequent  form  of 
fistulous  opening  occurs  in  the  septum  between  the  blad- 
der and  the  vagina.  The  condition  is  usually  caused  by 
sloughing,  the  result  of  prolonged  pressure  from  the  fetal 
head  at  labor. 

404 


GENITAL  FISTULA.  405 

In  some  cases  such  an  opening  is  made  for  therapeutic 
reasons  by  the  physician,  for  the  cure  of  cystitis. 

Intelligent  midwifery  and  the  prompt  and  proper  use 
of  the  obstetrical  forceps  have  greatly  diminished  the 
frequency  of  vesico-vaginal  fistula.  It  was  formerly  a 
very  common  disease.  At  the  present  day  it  is  but  rarely 
seen,  at  least  in  those  parts  of  the  country  where  women 
have  competent  attendance  at  labor. 

The  vesico-vaginal  opening  may  be  situated  at  any 
portion  of  the  septum.  It  varies  very  much  in  size  and 
shape.  It  may  be  a  small  hole  barely  admitting  a  fine 
probe-point,  a  median  slit,  or  a  large  irregular  opening 
involving  the  whole  base  of  the  bladder. 

The  appearance  of  the  fistula  varies  according  to  the 
time  that  has  elapsed  since  the  receipt  of  the  injury. 
The  margins  of  the  opening,  which  are  at  first  irregular 
and  ulcerated,  become  in  time  thin  and  firm  from  cicatri- 
cial contraction,  and  the  size  of  the  opening  becomes 
similarly  diminished. 

The  first  symptom  of  vesico-vaginal  fistiila  is  the  in- 
voluntary escape  of  urine  from  the  vagina.  If  the  con- 
dition has  resulted  from  pressure  at  parturition,  the  in- 
continence of  urine  does  not  appear  for  five  or  ten  days 
after  labor,  when  the  slough  has  separated.  When  a 
direct  laceration  of  the  vesico-vaginal  septum  has  oc- 
curred, the  urine  will  escape  immediately. 

The  degree  of  incontinence  varies  with  the  size  and 
the  position  of  the  fistula.  If  the  opening  is  small  and 
is  situated  in  the  upper  part  of  the  vagina,  there  may  be 
perfect  continence  when  the  woman  is  in  the  erect  posi- 
tion, as  long  as  the  urine  remains  below  the  level  of  the 
opening.  Incontinence  returns  when  the  accumulation 
of  urine  becomes  greater  than  this  and  when  the  woman 
assumes  the  recumbent  posture.  I  have  seen  a  woman 
with  a  fistula  of  this  kind  who  was  only  troubled  with 
incontinence  at  night. 

The  secondary  symptoms  of  vesico-vaginal  fistula  are 
due  to  the  irritation  of  the  urine.     Unless  the  greatest 


4o6     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

cleanliness  be  obsen,'ed,  great  suflfering  may  result  within 
a  few  weeks  after  the  receipt  of  the  injury.  The  vagina, 
the  labia,  and  the  inner  aspects  of  the  thighs  become  in- 
flamed and  excoriated.  The  mucous  membrane  of  the 
vagina  may  become  covered  with  an  offensive  phosphatic 
deposit.  If  the  fistulous* opening  be  large,  the  fundus  of 
the  bladder  may  prolapse  into  the  vagina  and  become 
covered  with  a  similar  deposit. 

Secondary  kidney  disease,  from  infection  of  the  ureters, 
may  follow  in  time. 

As  the  result  of  disuse  the  bladder  becomes  contracted, 
and  its  walls  become  thickened  from  inflammatory  infil- 
tration, so  that  when  the  fistula  is  closed  the  capacity  of 
the  bladder  is  much  less  than  normal.  Disuse  of  the 
urethra  results  also  in  contraction,  which  may  be  so  ex- 
tensive as  seriously  to  complicate  treatment. 

Physical  examination  usually  reveals  the  condition. 
The  woman  should  be  placed  in  the  Sims,  the  genu-pec- 
toral,  or  the  lithotomy  position,  and  the  anterior  vaginal 
wall  should  be  examined  through  the  Sims  speculum. 
The  examiner  should,  of  course,  determine  that  the  in- 
voluntary flow  of  urine  comes  from  the  vagina,  and  not 
from  the  urethra.  Women  are  often  unable  to  tell  accu- 
rately whence  the  urine  escapes,  and  the  single  symp- 
tom of  incontinence  of  urine  is  not  pathognomonic  of 
fistula. 

In  most  cases  the  fistulous  opening  may  be  readily 
detected,  and  a  sound  passed  through  the  urethra  may  be 
made  to  emerge  in  the  vagina.  In  the  case  of  small 
openings,  however,  obscurely  situated  in  the  upper  part 
of  the  vagina,  and  especially  in  case  of  vesico-uterine 
fistula,  it  may  be  diflScult  to  demonstrate  the  presence  of 
a  fistula.  In  such  cases  the  bladder  may  be  filled  with 
sterile  milk,  which  may  then  be  seen  escaping  into  the 
vagina.  This  is  a  valuable  method  of  diagnosis  in  the 
rare  cases  of  uretero-vaginal  fistula. 

Treatment. — The  method  of  curing  vesico- vaginal  fis- 
tula was  taught  to  the  world  by  IMarion  Sims,  who  ope- 


GENITAL  FISTULAI.  407 

rated  successfully  in  1849,  and  who  published  his  first 
article  upon  the  subject  in  1852. 

Careful  preparatory  treatment  before  operation  is  usu- 
ally necessary.  Unless  the  vagina  and  the  bladder  are  in 
a  healthy  condition  beforehand,  every  method  of  opera- 
tion is  likely  to  fail. 

It  is  necessary  to  treat  all  excoriations  or  ulcerations, 
to  cure  the  cystitis,  and  to  relieve  the  tension  of  all  bands 
of  scar-tissue  in  the  vagina  that  may  prevent  proper  ap- 
proximation of  the  edges  of  the  opening. 

The  phosphatic  deposit  should  be  carefully  removed 
from  the  vaginal  walls  and  the  interior  of  the  bladder 
with  a  soft  sponge  or  cotton,  and  a  weak  solution  of 
nitrate  of  silver  (gr.  v  to  sj)  should  be  applied  to  the  raw' 
surfaces. 

Frequent  warm  sitz-baths  should  be  administered  daily. 
The  vagina  should  be  washed  out  several  times  a  day 
with  large  quantities  of  sterile  hot  water  or  with  a  solu- 
tion of  boracic  acid  (.5j  to  the  pint). 

The  urine,  which  is  generally  alkaline,  should  be  ren- 
dered acid  by  the  use  of  benzoic  or  boracic  acid. 

Emmet  advises  the  following  prescription:  "2  drams 
of  benzoic  acid  and  3  drams  of  borax  to  12  ounces  of 
water,  of  which  a  tablespoonful,  further  diluted,  should  be 
given  three  or  four  times  a  day. ' '  After  the  urine  has 
become  acid  the  dose  may  be  reduced. 

Every  fifth  day  the  solution  of  nitrate  of  silver  should 
be  applied  to  the  unhealed,  excoriated  surfaces.  It  may 
be  necessary  to  pursue  this  treatment  several  weeks  be- 
fore the  parts  are  brought  to  a  healthy  condition.  Im- 
provement is  perceived  not  only  in  the  condition  of 
the  vaginal  walls  and  the  bladder,  but  in  the  edges  of 
the  fistula,  which,  in  place  of  being  hypertrophied  and 
indurated,  assume  a  natural  color  and  density. 

In  case  the  vaginal  fistula  be  small,  the  accompanying 
cystitis  may  be  difficult  to  cure,  because  there  is  always 
some  residual  urine  in  the  bladder.  It  may  then  be  ad- 
visable,  as  a  preparatory  step,    to  enlarge  the  fistulous 


4o8     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Opening  by  a  clean  incision  in  the  median  line,  in  order 
to  secure  more  perfect  drainage.  The  cystitis  may  be 
kept  up  by  the  presence  of  a  phosphatic  concretion  in  the 
bladder,  which  may  be  removed  in  this  way.  It  is  use- 
less to  close  the  fistula  until  the  cystitis  is  cured. 

In  every  case  of  vesico-vaginal  fistula  it  is  advisable 
to  examine  for  vesical  calculus,  that  the  bladder  may  not 
be  closed  with  a  calculus  in  it.  The  calculus  occasionally 
exists  before  the  formation  of  the  fistula,  and  perhaps  as- 
sists in  its  production,  the  vesico-vaginal  septum  being 
squeezed  between  the  child's  head  and  the  calculus.  Usu- 
ally, however,  the  calculus  forms  as  a  result  of  the  fistula. 
When  the  parts  have  been  brought  to  a  healthy  condi- 
tion the  fistula  should  be  examined  with  a  view  to  the 
method  of  closure.  The  opening  should  be  exposed  with 
the  Sims  speculum,  and  the  edges  at  opposite  points 
should  be  seized  with  tenacula  or  forceps  and  approxi- 
mated. In  this  way  the  surgeon  may  determine  the  di- 
rection in  which  the  fistula  may  be  closed  with  the  least 
traction  on  the  sutures.  When  possible,  it  is  advisable, 
in  order  to  prevent  shortening  of  the  vagina,  to  close  the 
fistula  in  the  direction  of  the  long  axis  of  the  vagina. 

If  the  edges  of  the  opening  cannot  readily  be  brought 
together,  any  restraining  bands  of  tissue  in  the  vaginal 
walls  should  be  divided  with  scissors.  If  these  bands  are 
slight  and  superficial,  they  may  be  divided  at  the  time  of 
operation  for  closure.  If,  however,  they  are  extensive, 
preparatory  treatment  devoted  to  the  liberation  of  the 
edges  of  the  fistula  must  be  practised.  All  restraining 
bands  should  be  freely  divided,  and  after  the  vagina  has 

thus  been  opened  up,  it 
should  be  distended  (to 
prevent  subsequent  con- 
traction) by  introducing  a 
vaginal    plug    or    dilator 

^IG.  i8i.-Sims'  vaginal  dilator.  (^i?'    ^^^)  ^\  ^  rubber  bag 

packed      with       sponges. 
Bleeding  is  generally  controlled  by  the  pressure  of  the 


GENITAL  FISTULA.  409 

plug.  The  vaginal  plugs  of  glass  or  of  hard  rubber  are 
made  of  various  sizes.  They  should  be  long  enough  and 
thick  enough  to  stretch  the  vagina  without  producing 
sloughing.     The  plug  is  retained  by  a  T-bandage. 

After  this  operation  the  woman  should  be  kept  in  bed 
for  a  week  or  ten  days.  The  urine  should  be  drawn  with 
the  catheter  without  removing  the  plug.  When  suppu- 
ration begins  the  plug  will  become  loosened  and  may  be 
removed,  Emmet  says:  "It  is  remarkable  how  much 
absorption  of  the  cicatricial  tissue  takes  place  in  a  few 
weeks  when  judicious  pressure  has  been  maintained  by 
this  instrument." 

After  removing  the  plug,  vaginal  douches  should  be 
resumed  until  healing  is  complete. 

It  will  be  seen  from  this  consideration  that  the  prepara- 
tory treatment  may  be  severe  and  may  extend  over  a  long 
period.  Such  extensive  treatment  is  not  by  any  means 
always  necessary;  when,  however,  it  is  required,  it  is  use- 
less to  proceed  to  operation  without  it. 

Operation. — The  operation  consists  in  freshening  the 
edges  of  the  fistula  with  the  knife  or  scissors  and  bring- 
ing them  into  apposition  with  the  interrupted  suture. 
Different  forms  of  suture  have  been  used  by  various  ope- 
rators. If  the  parts  are  in  a  healthy  condition  and  are 
properly  denuded  and  approximated,  it  makes  no  differ- 
ence in  the  result  what  form  of  suture  is  used.  As  in  all 
forms  of  plastic  work,  I  prefer  silkworm  gut  shotted. 
The  operation  is  most  easily  performed  with  the  woman 
in  the  Sims  position,  the  vagina  being  exposed  with  the 
Sims  speculum.  The  lithotomy  or  the  genu-pectoral 
position  is  preferred  by  some  operators.  The  edge  of  the 
opening  should  be  seized  with  the  tenaculum  or  with 
tissue-forceps,  and  a  continuous  strip  of  tissue  should  be 
removed  all  around  the  fistula,  extending  from  the  mu- 
cous membrane  of  the  bladder  out  upon  the  vaginal  sur- 
face for  a  quarter  or  three-eighths  of  an  inch.  The  vag- 
inal mucous  membrane  usually  retracts  somewhat  as  soon 
as  it  is  liberated  from  the  fistulous  margin,  so  that  the 


4IO      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

raw  surface  is  broader  than  the  strip  removed.  It  is  ad- 
visable to  avoid  any  injury  to  the  mucous  membrane  of 
the  bladder,  as  free  bleeding  may  take  place  from  this 
structure.  The  denuded  surface  should  extend  as  near  as 
possible  to  the  mucous  membrane  of  the  bladder  without 
involving  it. 

The  denudation  should  be  extended  some  distance  be- 
yond each  angle  of  the  fistula,  in  order  to  secure  perfect 
apposition  in  these  positions. 

The  length  and  shape  of  the  needle  used  for  closing 
the  opening  varies  with  the  fancy  of  the 
operator.  As  a  rule,  a  small  needle, 
straight  or  curved  at  the  point,  is  most 
convenient  (Fig.  182). 

The  needle  should  be  introduced  about 
an  eighth  of  an  inch  from  the  edge  of 
Fig.  182— Fistula-    the    vaginal     mucous     membrane,    and 
needles.  should  be  made  to  emerge  at  the  edge  of 

the  mucous  membrane  of  the  bladder. 
It  should  be  reintroduced  and  emerge  in  the  reverse  order 
on  the  opposite  side  (Fig.  183).  The  sutures  should  be 
placed  about  a  quarter  of  an  inch  apart. 

After  the  sutures  have  been  introduced,  and  before 
they  have  been  shotted  or  tied,  the  bladder  should  be 
thoroughly  washed  out  with  a  warm  boric-acid  solution. 
The  operator  should  make  sure  that  no  blood-clot  is  left 
in  the  bladder.  After  the  sutures  have  been  shotted  a 
light  gauze  tampon  may  be  placed  in  the  vagina. 
A  permanent  soft-rubber  catheter  may  be  introduced 
through  the  urethra,  or  the  urine  may  be  drawn  every 
three  or  four  hours  after  the  operation.  If  care  is  given 
to  the  cleanliness  of  the  catheter,  it  is  perhaps  best  to 
retain  it  in  the  bladder  for  three  or  four  days,  after  which 
the  urine  may  be  drawn  every  four  hours.  The  catheter 
should  be  removed  twice  in  twenty-four  hours  for  pur- 
poses of  cleansing.  The  eye  of  the  catheter  frequently 
becomes  obstructed  by  blood-clot. 

It  should  not  be  forpfotten  that  the  bladder  is  often 


GENITAL  FISTULA. 


411 


much  contracted  in  old  cases  of  vesico-vaginal  fistula, 
and  as  the  capacity  is  diminished  more  frequent  catheter- 
ization than  usual  is  necessary. 

Boric  or  benzoic  acid  should  be  continued  during  the 
convalescence. 

The  gauze  tampon  should  be  removed  on  the  second 
day. 

The  bowels  should  be  moved  on  the  second  or  third 


Fig.  183. — Vesico-vaginal  fistula  with  the  sutures  introduced. 

day.  The  sutures  may  remain  for  two  weeks.  The 
woman  may  sit  up  at  the  end  of  two  weeks. 

The  operation  described  here — more  or  less  modified 
in  order  to  meet  the  requirements  of  different  cases — 
will  result  in  cure  in  the  great  majority  of  instances. 
Often  much  depends  upon  the  ingenuity  and  the  me- 
chanical skill  of  the  operator.  Sometimes  two  or  three 
operations  are  necessary  before  the  opening  can  be  com- 
pletely closed,  the  operator  closing  part  at  each  sitting. 

In  the  case  of  a  small  fistulous  opening  it  may  be 


412     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

necessary  to  enlarge  it  by  free  incision  before  the  denuda- 
tion and  the  introduction  of  the  sutures  can  be  properly 
accomplished. 

In  the  very  rare  cases  which  are  incurable  by  operation 
kolpokleisis^  or  closure  of  the  vagina,  has  been  practised 
by  some.  The  operation  was  performed  by  removing  a 
circular  strip  around  the  circumference  of  the  vagina, 
immediately  above  the  ostium  vaginae,  and  approximat- 
ing the  raw  surfaces  by  a  transverse  row  of  sutures. 
This  operation  makes  of  the  bladder  and  the  vagina  one 
urinary  pouch  into  which  menstrual  blood  and  uterine  dis- 
charges flow.  It  should  never  be  practised.  I  quote  from 
Hmmet  in  this  connection:   "From  my  own  observation 

1  have  learned  that  it  is  but  a  question  of  a  few  months, 
a  year,  or  possibly  two  years,  before  serious  consequences 
must  arise  after  leaving  a  receptacle,  like  a  portion  of  the 
vagina,  in  which  the  urine  may  stagnate.  To  give  a 
retentive  power  for  so  short  a  time  is  not  a  sufficient 
compensation  for  the  suffering  and  consequences  that 
supervene.  As  the  result  of  my  experience,  I  would 
urge  that  the  operation  never  be  resorted  to  under  any 
circumstances.     The  maximum  has  now  been  reduced  to 

2  or  3  per  cent,  of  cases  where  the  resources  of  the  sur- 
geon cannot  overcome  all  the  difficulties  that  may  be 
presented  in  closing  a  vesico- vaginal  fistula." 

The  forms  of  operation  in  which  the  cervix  uteri  is 
utilized  to  assist  in  the  closure  of  a  vesical  fistula,  as  a 
result  of  which  the  menstrual  blood  and  the  uterine 
secretions  are  discharged  into  the  bladder,  are  contrain- 
dicated  for  similar  reasons. 

Urethro-vaginal  fistula  is  much  less  common  than 
vesical  fistula.  Unless  the  neck  of  the  bladder  be  in- 
volved, there  may  be  perfect  control  of  urine;  though, 
of  course,  when  the  urine  is  voided  it  will  escape  from 
the  ostium  vaginae,  and  not  from  the  external  meatus. 

The  treatmeitt  of  urethro-vaginal  fistula  is  essentially 
the  same  as  that  already  described  for  vesico-vaginal 
fistula.     The  edges  should  be  denuded,  and  the  opening 


GENITAL  FISTULA.  413 

into  the  urethra  closed  over  a  large-sized  catheter.  The 
line  of  union  should  be  in  the  long  axis  of  the  urethra. 

Vesico-uterine  fistula. — In  this  form  of  fistula  the 
opening  usually  extends  from  the  bladder  into  the  cervi- 
cal canal.  It  is  caused  by  labor  in  which  the  anterior 
lip  of  the  cervix  is  lacerated.  The  lower  portion  of  the 
cervical  laceration  may  unite,  leaving  the  fistulous  open- 
ing above. 

The  diagnosis  of  the  condition  is  made  from  observing 
urine  escape  from  the  cervical  canal,  or  by  injecting  the 
bladder  with  milk  or  other  colored  fluid.  A  sound  intro- 
duced in  the  cervix  may  be  brought  in  contact  with  a  probe 
passed  through  the  urethra  and  bladder  into  the  fistula. 

If  these  methods  of  examination  are  not  satisfactory, 
endoscopic  examination  of  the  interior  of  the  bladder 
will  reveal  the  abnormal  opening. 

The  treatmeitt  consists  in  dividing  the  anterior  lip  of 
the  cervix  and  the  vaginal  wall  down  to  the  fistulous 
tract;  thorough  denudation  of  the  walls  of  the  fistula; 
and  closure  of  the  whole  incision  by  interrupted  sutures. 

Uretero-vaginal  Fistula. — This  condition  is  usually 
the  result  of  injury  to  the  ureter  by  operation.  It  may 
occur  from  the  destruction  of  tissue  caused  by  pelvic 
abscess,  which  discharges  through  the  vaginal  vault.  In 
extensive  vesico-vaginal  fistula  caused  by  sloughing  after 
labor  the  bladder- wall  may  become  rolled  out  so  that  the 
ureter  opens  into  the  vagina. 

If  but  one  ureter  is  involved,  one-half  of  the  urine 
will  be  discharged  in  the  natural  way  and  the  other  half 
by  the  vagina. 

The  treatment  consists  in  directing  the  ureter  into  the 
bladder  by  plastic  operation  performed  through  the  va- 
gina; or  by  performing  celiotomy,  dissecting  out  the 
ureter,  and  implanting  it  in  the  fundus  of  the  bladder. 

Recto-vaginal  Fistula. — Recto-vaginal  fistula  is  usu- 
ally caused  by  parturition.  The  destruction  of  tissue  is 
sometimes  due  to  syphilis.  In  the  latter  case  cure  is  dif- 
ficult, and  sometimes  impossible. 


414      ^  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  symptom  of  the  condition  is  the  passage  of  feces 
and  flatus  into  the  vagina. 

Sometimes  but  a  very  small  opening  exists,  situated 
immediately  above  the  sphincter  muscle;  in  other  cases 
the  greater  portion  of  the  recto-vaginal  septum  is  de- 
stroyed. 

The  condition  may  be  recognized  by  placing  the  woman 
in  the  lithotomy  position  and  exposing  the  posterior  vag- 
inal wall  by  the  Sims  speculum  placed  under  the  pubic 
arch. 

The  treatment  consists  in  operation  similar  to  that  de- 
scribed under  the  consideration  of  vesico-vaginal  fistula. 
The  woman  should  be  prepared  as  for  a  plastic  operation 
upon  the  perineum.  The  rectum  should  be  thoroughly 
emptied  before  operating.  The  sphincter  ani  should  be 
stretched.  It  is  always  advisable,  when  possible,  to  close 
the  opening  from  the  vagina. 

The  mucous  membrane  of  the  rectum  should  be  in- 
jured as  little  as  possible,  in  order  to  limit  the  bleeding. 
It  may  be  necessary  to  relieve  tension  on  the  edges  of  the 
fistula  by  making,  on  each  side  of  the  vaginal  aspect  of 
the  opening,  an  incision  parallel  to  the  long  axis  of  the 
vagina. 

In  case  of  a  small  fistula  situated  immediately  above 
the  sphincter  ani,  it  is  sometimes  difficult  to  denude  and 
to  introduce  the  sutures.  It  then  becomes  necessary  to 
divide  the  perineum  and  the  sphincter  ani  to  the  fistula, 
denude  the  edges,  and  to  introduce  sutures  as  in  a  case 
of  complete  median  laceration  of  the  perineum.  Some- 
times the  recto-vaginal  fistula  is  much  larger  on  the  vag- 
inal than  on  the  rectal  aspect — is,  in  fact,  funnel-shaped, 
the  destruction  of  tissue  having  been  greater  upon  the 
vaginal  surface.  If  in  such  a  case  the  edges  of  the  fistula 
cannot  be  brought  into  apposition  after  freeing  all  re- 
straining bands,  it  may  be  necessary  to  split  the  edge  of 
the  opening,  so  that  the  rectal  wall  is  freed  and  may  be 
brought  together  by  sutures  introduced  through  the  rec- 
tum, leaving  the  vaginal  opening  to  be  filled  by  granula- 


GENITAL  FISTULA.  415 

tion.  The  rectal  sutures  may  be  introduced  by  placing 
the  woman  in  the  Sims  position  and  exposing  the  ante- 
rior rectal  wall  with  the  Sims  speculum. 

The  after-treatment  resembles  in  all  respects  that  pre- 
scribed after  operation  for  laceration  through  the  sphinc- 
ter ani.     The  sutures  should  be  removed  in  two  weeks. 


CHAPTER   XXXVII. 
DISEASES  OF  THE  URETHRA  AND  BLADDER. 

Before  considering  in  detail  the  diseases  of  the  ure- 
thra and  bladder,  it  will  be  necessary  to  describe  the 
modern  methods  of  examining  these  structures. 

The  examination  of  the  urethra  and  bladder  has  been 
very  much  facilitated  by  the  methods  and  instruments 
that  have  been  popularized  in  this  country  by  Kelly. 
The  following  apparatus  is  required:  a  female  catheter; 
a  urethral  calibrator;  a  series  of  specula  with  obturators; 
a  head-mirror  and  light  or  an  electric  headlight;  long, 
delicate  toothed  forceps  (Fig.  184);  an  inclined  plane  or 


Fig.  184. — Mouse-tooth  forceps  for  bladder. 

several  hard  pillows  for  elevating  the  pelvis;  small  balls 
of  absorbent  cotton  about  the  size  of  a  pea,  or  strips  of 
absorbent  gauze  cut  i  inch  in  width  and  about  10  inches 
long,  for  drying  out  the  bladder. 


Fig.  185. — Urethral  dilator:  short  lines  indicate  diameter  in  millimeters. 

The  urethral  calibrator  or  dilator  (Fig.  185)  is  a  conical 
metal  instrument  with  a  maximum  diameter  of  twenty 
millimeters.  The  diameters  in  millimeters  of  the  vari- 
ous portions  are  indicated  by  numbers  upon  the  instru- 
ment. 

416 


DISEASES  OF  THE  URETHRA  AND  BLADDER.     417 

The  urethral  calibrator  is  useful  for  dilating  the  ex- 
ternal meatus  to  a  degree  sufficient  to  admit  the  necessary 
speculum.  The  external  meatus  is,  as  a  rule,  the  only 
portion  of  the  urethra  that  requires  dilatation.  Any  in- 
strument that  will  pass  through  the  meatus  will  pass 
through  the  rest  of  the  canal. 

The  speculum  (Fig.  186)  is  a  cylindrical  metal  tube 
fitted  with  a  handle  on  which  is  the  number  indicating 


Fig.  186. — Kelly's  cystoscope  or  vesical  speculum. 


the  size  of  the  instrument.  There  are  a  number  of  spec- 
ula, varying  in  diameter  from  5  to  20  millimeters.  Each 
speculum  is  fitted  with  an  obturator.  The  most -useful 
specula  are  those  ranging  from  8  to  12  millimeters  in  diam- 
eter. The  urethra  may  readily  be  dilated  up  to  12  milli- 
meters, with  little  if  any,  external  laceration.  Dilatation 
sufficient  to  admit  the  largest  instrument  (20  millimeters) 
is  always  accompanied  by  considerable  laceration  of  the 
urethral  opening.  Dilatation  of  the  urethra  should  never 
be  practised  beyond  this  degree,  on  account  of  the  danger 
of  subsequent  incontinence  of  urine. 

An  anesthetic  is  usually  required  for  the  examination, 
unless  the  woman  be  capable  of  enduring  considerable 
pain,  or  has  become  accustomed  to  the  procedure  from 

27 


4i8      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

previous  experience.      Local  anesthesia  of   the   urethra 
with  cocaine  (gr.  x  to  5J)  is  often  sufficient. 

The  woman  is  placed  on  the  table  in  the  lithotomy- 
position,  and  the  bladder  is  emptied  with  the  catheter. 
The  external  meatus  is  then  dilated  to  the  requisite  size 
by  inserting  the  graduated  calibrator  with  a  general  ro- 
tary movement.  When  the  meatus  has  been  stretched 
sufficiently,  as  indicated  by  the  number  on  the  calibrator 
(usually  about  12  millimeters),  the  instrument  is  with- 
drawn, and  the  speculum  of  corresponding  number,  armed 
with  the  obturator,  is  introduced;  the  obturator  is  then 
removed. 

The  hips  of  the  woman  are  now  elevated  on  the  pillows 
or  the  inclined  plane  from  10  to  20  inches  above  the  level 
of  the  table. 

The  examiner,  armed  with  the  head-mirror  or  light,  is 
then  prepared  to  inspect  the  interior  of  the  bladder.  If 
the  mirror  is  used,  the  light  (Argaud  burner  or  electric 
drop-light)  should  be  held  close  to  the  pubis  of  the  pa- 
tient. 

Usually  a  small  quantity  of  urine  remains  in  the 
bladder  after  catheterization,  or  is  secreted  during  the 
preliminary  procedures,  and  it  is  necessary  to  remove 
this  before  complete  examination  of  the  bladder  can  be 
made.  This  may  be  done  by  means  of  the  small  balls  of 
absorbent  cotton  or  the  strips  of  gauze  grasped  with  the 
long  toothed  forceps  and  passed  in  through  the  speculum. 


Fig.  187. — Vesical  probe  or  applicator. 


The  elevated  position  of  the  hips  is  an  essential  part 
of  this  method  of  examination;  it  permits  the  intestines 
to  gravitate  out  of  the  pelvis,  and,  as  soon  as  the  urethra 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    419 

is  opened,  the  bladder  becomes  distended  with  air,  so  that 
all  of  its  interior  may  be  readily  inspected,  and  applica- 
tions to  the  surface  may  be  directly  made  through  the 
speculum.  In  some  cases  it  is  difficult  to  produce  the 
requisite  distention  of  the  bladder  by  elevating  the  hips. 
This  difficulty  may  arise  in  the  case  of  very  fat  women. 
It  then  becomes  necessary  to  place  the  patient  in  the 
knee-chest  position,  when  the  requisite  distention  is 
readily  accomplished. 

As  the  speculum  is  withdrawn  from  the  bladder  the  in- 
ternal meatus  and  the  urethral  walls  may  be  examined  as 
they  fall  together  beyond  the  distal  end  of  the  instrument. 

DISEASES  OF  THE  URETHRA. 

The  female  urethra  is  a  musculo-membranous  canal 
averaging  i^  inches  in  length,  and,  when  not  stretched, 
about ^  inch  in  diameter.  The  urethra  is  normally  closed 
by  the  apposition  of  its  walls.  In  the  neighborhood  of 
the  external  meatus  it  is  an  antero-posterior  slit.  In  the 
neighborhood  of  the  internal  meatus  it  is  a  transverse 
slit.  In  the  middle  portion  the  mucous  membrane  is 
arranged  in  longitudinal  folds,  and  a  transverse  section 
shows  a  stellate  closure. 

The  muscular  coat  of  the  urethra  contains  both  striped 
and  unstriped  muscular  fibers. 

The  mucous  glands  of  the  urethra  are  most  numerous 
in  the  region  of  the  external  meatus.  Skene  first  de- 
scribed two  glands  that  are  worthy  of  special  mention. 
Skene's  glands  are  two  tubules,  large  enough  to  admit  a 
No.  I  probe  of  the  French  scale,  that  lie  upon  the  floor 
of  the  urethra  immediately  within  the  external  meatus. 
They  lie  parallel  to  the  long  axis  of  the  urethra,  and  in 
length  vary  from  ^  to  ^  of  an  inch.  They  are  placed 
beneath  the  mucous  membrane,  in  the  muscular  coat. 
The  orifices  of  the  glands  are  on  the  free  surface  of  the 
mucosa,  immediately  within  the  external  meatus.  In 
young  women  the  orifices  are  found  about  yi  of  an  inch 
above  the  plane  of  the  external  meatus.     If  the  external 


420      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

meatus  be  patulous,  or  if  there  be  any  prolapse  or  inflam- 
mation of  the  mucous  membrane  of  the  urethra,  the  ori- 
fices of  Skene's  glands  may  be  seen  upon  each  side  of 
the  urethral  orifice  as  soon  as  the  labia  are  separated. 
In  gonorrhea  their  position  is  often  indicated  by  a  small 
drop  of  pus  exuding  from  the  orifices.  The  upper  ends 
of  the  glands  may  terminate  in  a  number  of  divisions. 

Urethritis. — Urethritis  is  much  less  frequent  in  women 
than  in  men.  In  the  great  majority  of  cases  it  is  caused 
by  gonorrhea.  Aside  from  microscopic  examination,  ure- 
thritis, acute  or  chronic,  may  be  considered  one  of  the 
strongest  evidences  of  gonorrheal  infection  that  we  have. 

Urethritis  is  also  rarely  caused  by  the  exanthematous 
diseases,  irritation  of  concentrated  urine,  vaginal  dis- 
charges,  chemical  irritants,  and  traumatism. 

Symptoms. — The  symptoms  of  urethritis  in  the  acute 
stage  of  the  disease  are  frequent  and  painful  urination. 
Burning  and  scalding  sensations  are  experienced  along 
the  course  of  the  urethra  during  urination.  Occasion- 
ally a  few  drops  of  blood  escape  during  or  after  urina- 
tion. As  the  disease  progresses  toward  cure  or  passes 
into  the  chronic  stage,  the  intensity  of  these  symptoms 
diminishes,  and  finally  they  disappear. 

Examination  of  the  parts  shows  that  the  external 
meatus  is  red  and  swollen.  The  swollen  mucous  mem- 
brane may  bulge  through  the  opening,  giving  the  appear- 
ance of  prolapse.  The  orifices  of  Skene's  glands  may 
be  conspicuous.  If  the  woman  have  not  recently  uri- 
nated, a  drop  of  pus  may  appear  at  the  meatus,  or  it  may 
be  brought  into  view  by  vaginal  pressure  along  the  course 
of  the  urethra.  Pressure  upon  the  urethra  through  the 
vagina  causes  pain.  This  is  one  of  the  best  tests  of  in- 
flammation of  this  structure.  The  urethra  may  feel 
hypertrophied,  indurated,  or  cord-like  to  the  touch.  The 
urethral  discharge  should  always  be  examined  micro- 
scopically for  the  gonococci. 

In  chronic  urethritis  the  subjective  symptoms  are  usu- 
ally  absent — except,    perhaps,    frequency    of    urination. 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    421 

The  diagnosis  is  made  by  physical  examination.  If  the 
woman  has  not  urinated  for  several  hours,  the  examiner 
will  be  able  to  express,  by  vaginal  pressure  along  the 
course  of  the  urethra,  a  drop  of  muco-purulent  fluid  re- 
sembling the  gleety  discharge  of  the  male. 

The  endoscope  reveals  the  presence  of  congestion  and 
inflammation  of  the  mucous  membrane. 

Treatifient. — In  the  acute  or  the  painful  stage  of  the 
disease  no  local  applications  should  be  made.  The  ex- 
ternal genitals  should  be  bathed  several  times  a  day  with 
hot  water,  preferably  by  means  of  sitz -baths.  Vaginal 
douches  are  not  indicated  unless  the  vagina  be  involved 
in  the  inflammation.  The  vaginal  syringe  may  be  the 
means  of  carrying  infection  higher  up  in  the  genital 
tract.  Rest  in  the  recumbent  position,  if  possible,  is 
desirable.  The  diet  should  be  non-stimulating,  and 
large  quantities  of  diluent  drinks,  such  as  flaxseed  tea, 
should  be  prescribed.  The  bowels  should  be  kept  loose 
by  saline  purgatives. 

In  the  subacute  or  the  chronic  stages  of  the  disease 
boracic  acid  (gr.  x-xx  three  or  four  times  a  day),  salol, 
oil  of  sandal-wood,  cubebs,  copaiba,  and  other  driigs 
used  for  the  similar  condition  in  the  male  are  indicated. 
After  painful  micturition  has  ceased,  the  physician  may 
make  local  applications  to  the  urethra,  in  case  the  in- 
flammation does  not  subside  satisfactorily  without  them. 
Such  local  applications  are  not  always  necessary,  and 
they  may  do  harm  unless  proper  care  is  exercised  in  their 
administration.  Asepsis  and  gentleness  are  necessary,  and 
the  applications  should  never  be  too  strong  or  irritating. 

Frequent  douching  of  the  urethra  (two  or  three  times 
a  day  if  possible)  with  sterile  hot  water  is  often  of  much 
benefit.  Skene's  reflux  catheter  should  be  used  (Fig. 
188).  The  shaft  of  this  instrument  is  fluted  or  grooved 
to  permit  the  return  of  the  fluid.  The  catheter  should 
be  introduced  as  far  as  the  internal  meatus  ;  a  fountain 
syringe  should  be  attached  to  it,  and  the  urethra  should 
be  washed  out  with  a  quart  of  hot  water. 


422      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

After  the  irrigation  the  catheter  should  be  withdrawn 
and  a  urethral  injection  of  nitrate  of  silver  (gr.  j  or  ij  to 
oj)  should  be  administered.  The  injection  may  be  given 
by  means  of  a  glass  pipette  the  nozzle  of  which  is  large 
enough  to  encircle  the  external  meatus.  The  nozzle 
should  be  placed  over,  not  in,  the  meatus.  The  female 
urethra  will  hold  about  15  minims  of  fluid;  more  than 


Fig.  1S8. — Skene's  reflux  catheter. 


this  should  not  be  injected.  As  the  condition  improves 
the  frequency  of  these  treatments  may  be  diminished. 

If  the  condition  does  not  yield  to  such  treatment  within 
a  few  weeks,  application  should  be  made  directly  to  the 
mucous  membrane  of  the  urethra  through  the  endo- 
scope. The  urethral  canal  should  be  washed  out  as  just 
described,  and  the  endoscope  should  be  introduced  as  far 
as  the  internal  meatus.  As  it  is  slowly  withdrawn  the 
application  should  be  made  over  the  whole  inner  surface 
of  the  urethra  by  a  fine  applicator  wrapped  with  cotton. 
Nitrate  of  silver  (gr.  v-x  to  sj)  should  be  employed. 

Sometimes  it  is  found  that  the  suppuration  persists  in 
Skene's  glands.  A  small  drop  of  pus  may  be  found 
exuding  from  the  orifice  of  the  gland  after  the  rest  of  the 
urethra  has  been  restored  to  a  healthy  condition.  In  such 
a  case  the  gland  should  be  split  up  on  the  urethral  sur- 
face by  introducing  into  it  one  blade  of  a  fine  scissors, 
and  the  tract  should  be  carefully  wiped  out  with  pure 
carbolic  acid  or  a  strong  solution  of  nitrate  of  silver. 

In  every  case  of  urethritis  of  gonorrheal  origin  it  is  of 
the  greatest  importance  that  every  trace  of  the  disease 
should  be  eradicated  before  the  patient  gives  up  treat- 
ment. There  is  always  danger  of  infection  extending  to 
the  upper  parts  of  the  genital  tract. 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    423 

Stricture  of  the  Urethra. — Stricture  of  the  urethra 
in  the  woman,  unlike  the  similar  condition  in  the  male, 
is  very  rare.  It  is  caused  by  gonorrhea,  injury  at  child- 
birth or  other  traumatism,  and  caustic  applications.  The 
stricture  may  exist  at  any  part  of  the  urethral  canal. 
The  form  most  usually  seen  is  that  which  occurs  at  the 
external  meatus,  and  is  caused  by  the  removal  of  abnor- 
mal growths  with  caustic  or  with  the  knife. 

The  symptoms  of  urethral  stricture  in  women  are  much 
less  marked  than  those  in  men.  There  is  frequent  and 
difficult  urination.  Occasionally  there  is  incontinence  or 
partial  retention  of  urine. 

If  the  stricture  exist  at  the  external  meatus,  it  may  be 
readily  seen  and  its  dimensions  determined.  If  it  exist 
in  the  upper  portion  of  the  urethral  canal,  it  may  some- 
times be  felt  by  palpation  along  the  course  of  the  urethra 
through  the  vagina,  the  position  of  the  stricture  being 
indicated  by  local  thickening  and  induration.  Its  loca- 
tion may  also  be  determined,  as  in  man,  by  the  use  of  the 
bulbous  bougie  or  sound. 

Treatment. — When  the  stricture  is  situated  at  the  ex- 
ternal meatus,  it  may  be  divided  with  the  knife  or  forci- 


FlG.  189. — Female  urethral  sound. 

bly  stretched.  When  it  is  situated  in  the  upper  portion 
of  the  urethra,  it  is  best  treated  by  forcible  dilatation. 

The  small  uterine  dilator  is  the  most  convenient  in- 
strument to  use.  The  dilatation  should  not  extend  be- 
yond half  an  inch,  for  fear  of  injuring  the  urethral  walls 
or  producing  incontinence.  In  order  to  prevent  contrac- 
tion, it  is  advisable  to  pass  the  large  urethral  sound  (lO' 
millimeters)  at  intervals  of  one  or  two  days  after  this  ope- 
ration, until  the  patency  of  the  urethra  is  ensured. 

In  some  cases  the  continual  subsequent  use  of  the  sound. 


424      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

is  necessary,  as  in  stricture  in  the  male.  The  woman 
may  be  readily  taught  the  use  of  the  instrument  herself. 

Prolapse  of  the  Mucous  Membrane  of  the  Ure- 
thra.— Prolapse  of  the  urethral  mucous  membrane  is  of 
unusual  occurrence.  Prolapse  may  be  limited  to  part  of 
the  circumference  of  the  meatus,  or  it  may  extend  around 
the  whole  canal.  The  condition  is  usually  found  in  weak, 
debilitated  women.     It  may  occur  during  childhood. 

The  prolapse  may  be  caused  by  dilatation  of  the  ure- 
thra and  the  external  meatus  or  by  the  traction  of  a  neo- 
plasm of  the  urethra.  It  sometimes  occurs  after  labor. 
It  may  be  produced  by  continual  vesical  tenesmus,  the 
result  of  cystitis,  calculus,  or  a  tumor  of  the  bladder. 

The  symptoms^  vesical  tenesmus  and  dysuria,  are  usu- 
ally present.  Sometimes  incontinence  of  urine  occurs. 
The  protruding  mucous  membrane  may  become  irritated 
and  inflamed,  and  cause  much  local  pain.  It  has  been 
known  to  slough  off. 

Treat7nent. — The  treatment  should  be  directed,  in  the 
first  place,  to  the  relief  of  any  causative  condition,  such 
as  cystitis  or  calculus. 

Inflammation  of  the  protruding  mucous  membrane 
should  be  relieved  by  local  applications  of  hot  water  and 
b}^  rest  in  bed.  The  mucous  membrane  should  then  be 
gently  replaced  within  the  urethra,  and  contraction  of 
the  canal  should  be  promoted  by  the  use  of  astringent 
injections  of  tannic  acid  or  alum. 

If  the  disease  does  not  yield  to  this  treatment,  the  pro- 
lapsed mucous  membrane  should  be  excised,  and  the  edges 
of  the  mucosa  should  be  stitched  to  the  margin  of  the 
meatus  by  fine  suture. 

After  this  operation  there  is  sometimes  cicatricial  con- 
traction of  the  external  meatus,  which  may  readily  be 
cured  by  forcible  dilatation. 

Vesico -urethral  Fissure. — Vesico-urethral  fissure  is 
an  ulcerated  crack  of  the  mucous  membrane  situated  at 
the  internal  urinary  meatus.  The  upper  portion  extends 
into   the   bladder,   the   lower  portion  is  in  the  urethra. 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    425 

Skene  describes  it  as  "from  ^  to  f  of  an  inch  in 
length,  and  from  -ji^-  to  -|-  of  an  inch  in  width  at  the  cen- 
ter, but  tapering  off  at  each  end.  The  deepest  part  has 
a  yellowish-gray  color,  like  that  of  an  indolent  ulcer, 
while  the  edges  are  red  and  actually  inflamed,  like  those 
of  an  irritable  ulcer." 

Vesico-urethral  fissure  is  usually  caused  by  urethritis. 
It  may  also  result  from  injuries  during  confinement  or 
from  the  bungling  use  of  the  catheter. 

Symptoms. — There  is  a  constant  desire  to  urinate,  and 
urination  is  followed  by  severe  tenesmus.  There  is  a 
burning  pain  at  the  neck  of  the  bladder,  increased  im- 
mediately after  urination.  Pressure  upon  the  internal 
meatus  through  the  vagina  may  cause  lancinating  pain. 


Fig.  190. — Skene's  urethral  endoscope. 

The  symptoms  resemble  closely  those  of  urethritis  and 
cystitis. 

The  diagnosis  of  vesico-urethral  fissure  can  be  made 
with  certainty  only  by  seeing  the  fissure  through  the 
endoscope.  The  existence  of  the  condition  may  be  sus- 
pected in  a  woman  who  presents  the  symptoms  just  de- 
scribed, and  in  whom  no  signs  of  inflammation  or  other 
disease  of  the  urethra  or  the  bladder  can  be  detected. 

The  open  endoscope  is  not  satisfactory  for  detecting 
this  condition,  because  the  fissure  is  hidden  from  view  by 
the  folds  of  mucous  membrane  at  the  upper  end  of  the 
instrument.     Skene,  who  has  especially  directed  atten- 


426     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

tion  to  vesico-urethral  fissure,  states  that  he  never  was 
able  to  detect  the  lesion  until  he  used  the  form  of  endo- 
scope introduced  by  him  (Fig.  190),  which  consists  of  a 
small  glass  tube  like  the  ordinary  test-tube,  into  which 
is  passed  a  mirror  on  a  holder.  The  instrument  is  passed 
into  the  urethra,  and  light  is  thrown  in  by  means  of  the 
concave  head-mirror.  By  moving  the  small  mirror  in 
the  tube,  different  parts  of  the  urethral  walls  may  be  ex- 
amined. The  instrument  opens  out  the  folds  of  mucous 
membrane  immediately  above  the  fissure  and  renders  it 
visible. 

Treatment. — The  cure  of  vesico-urethral  fissure  is  often 
difficult.  The  lesion  is  exposed  to  continuous  irritation 
from  the  urine  and  from  the  sphincteric  action  of  the 
muscular  fibers  at  the  vesical  neck — an  action  which  is 
much  increased  by  the  tenesmus  present.  This  constant 
muscular  action  impedes  healing,  as  in  the  case  of  fissure 
of  the  anus.  The  internal  urinary  meatus  should  be 
dilated  to  the  fullest  extent  by  means  of  the  graduated 
bougies  or  the  uterine  dilator.  After  dilatation  the  wom- 
an should  be  kept  in  bed,  and  the  urine  should  be  ren- 
dered as  unirritating  as  possible  by  the  use  of  diluent 
drinks  and  boracic  acid. 

If  this  treatment  does  not  result  in  cure,  a  vesico-vag- 
inal  fistula  should  be  made,  so  that,  by  carrying  off  the 
urine  by  this  means,  rest  from  functional  activity  will  be 
furnished  to  the'region  of  the  vesical  neck. 

No  effort  need  be  made  to  keep  the  fistula  open,  as  by 
the  time  it  has  closed  spontaneously  the  fissure  will  have 
healed. 

URETHRAL  NEOPLASMS. 

Urethral  Caruncle. — The  urethral  caruncle  is  a  small 
raspberry-like  tumor  situated  at  or  just  inside  of  the  ex- 
ternal meatus.  It  is  composed  of  dilated  capillaries  set  in 
a  dense  stroma  of  connective  tissue  and  covered  with 
mucous  membrane.  The  tumor  varies  in  size  from' a 
pin-head  to  a  hickory-nut.     In  color  it  varies  from  a  pale 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    427 

to  a  bright  red.  It  is  usually  situated  upon  the  posterior 
wall  of  the  urethra.  There  may  be  two  or  more  such 
tumors  around  the  circumference  of  the  meatus,  and  oc- 
casionally they  are  found  in  the  vestibule.  The  growth 
is  usually  sessile. 

The  caruncle  is  often  erectile  in  character,  and  increases 
in  size  at  the  menstrual  period. 

The  growths  bleed  very  easily  on  manipulation,  and 
are  exquisitely  sensitive.  The  urethral  caruncle  is  the 
commonest  neoplasm  of  the  urethra. 

Symptoms. — The  most  marked  symptom  of  urethral 
caruncle  is  pain.  Intense  pain  is  experienced  at  mictu- 
rition and  upon  contact  with  the  clothing  or  with  another 
body.  Sexual  connection  is  sometimes  rendered  impos- 
sible. 

There  is  usually  more  or  less  hemorrhage  from  the 
tumor,  which  may  rarely  be  so  profuse  as  to  cause  marked 
anemia.  The  general  health  suffers,  and  nervous  symp- 
toms, resulting  from  the  pain  and  loss  of  sleep,  are  often 
present  to  a  pronounced  degree. 

Treatment. — The  treatment  consists  in  the  total  ex- 
tirpation of  the  growth.  It  should  be  picked  up  with 
forceps  and  excised  with  the  knife  or  scissors.  The  edges 
of  the  mucous  membrane  should  be  united  by  sutures. 

Excision  should  be  complete  or  the  tumor  may  return. 
In  case  of  recurrence  a  second  operation  should  be  per- 
formed. 

Urethral  Cysts. — Small  cysts  are  occasionally  found 
in  the  course  of  the  urethra.  They  may  occur  at  any 
point  from  the  internal  to  the  external  meatus.  They 
are  caused  by  obstruction  and  distention  of  the  urethral 
glands.  They  produce  no  symptoms  unless  large  enough 
to  cause  obstruction  to  the  flow  of  urine.  They  may  be 
seen  by  the  endoscope  or  may  be  palpated  through  the 
vaginal  wall. 

The  treatment  consists  of  incision  and  removal  of  part 
of  the  cyst-wall. 

Polypus.— Mucous  polyp  of  the  urethra  is  of  very  rare 


428      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

occurrence.  The  tumor  generally  has  a  delicate  ped- 
icle, and  may  protrude  from  the  meatus.  It  is  painless, 
and  causes  discomfort  only  by  obstructing  the  flow  of 
urine. 

The  treatment  consists  of  removal  by  torsion,  ligature, 
or  excision. 

Sarcoma  and  cancer  of  the  urethra  have  rarely  been 
observed.  The  phenomena  are  those  similar  to  cancer  in 
other  parts  of  the  body. 

The  treatment  consists  in  thorough  removal, 

DISEASES  OF  THE  BLADDER. 

The  urinary  bladder  has  three  coats — an  outer  incom- 
plete peritoneal  investment,  a  middle  muscular  coat,  and 
an  inner  lining  of  mucous  membrane. 

The  empty  bladder  is  always  collapsed,  its  walls  being 
in  apposition.  A  median  sagittal  section  of  the  bladder 
and  urethra  shows  a  Y-shaped  fissure  lying  between  the 
symphysis  pubis  and  the  uterus,  the  uterus  lying  ante- 
verted  upon  the  upper  surface  of  the  bladder. 

For  convenience  of  description  the  bladder  is  divided 
into  three  parts — the  corpus,  or  body;  the  fundus,  or  base; 
and  the  cervix,  or  neck. 

The  body  of  the  bladder  is  all  that  portion  that  lies 
above  the  plane  of  the  vesical  orifices  of  the  ureters  and 
the  center  of  the  symphysis  pubis. 

The  part  lying  below  this  plane  is  the  base. 

The  vesical  triangle,  or  the  trigone,  is  that  triangular 
area  in  the  base  of  the  bladder,  the  angles  of  which  are 
marked  by  the  vesical  orifices  of  the  ureters  and  the  in- 
ternal meatus  of  the  urethra. 

The  neck  of  the  bladder  is  the  funnel-shaped  portion 
where  the  bladder  merges  into  the  urethra. 

The  mucous  membrane  of  the  bladder  is  covered  partly 
with  squamous,  partly  with  cylindrical  epithelium.  The 
mucous  membrane  is  loosely  attached  to  the  muscular 
coat  throughout  the  body  of  the  bladder,  so  that  when 
the  organ  is  contracted  the  membrane  is  thrown  into  un- 


DISEASES  OF  THE  URETHRA  AND  BLADDER.     429 

even  folds.  The  mucous  membrane  is  much  more  closely 
attached  to  the  underlying  structures  in  the  region  of  the 
vesical  triangle,  and  it  here  preserves  a  smooth  surface 
when  the  bladder  is  collapsed. 

The  vesical  triangle  is  more  richly  supplied  with 
nerves  than  are  the  other  portions  of  the  bladder,  and  is 
consequently  the  most  sensitive  portion. 

The  vesical  orifice  of  the  ureter  appears  as  a  dimple,  a 
small  truncated  cone,  or  a  pin-hole  or  slit  on  the  mucous 
membrane. 

A  transverse  band  or  fold  of  mucous  membrane,  known 
as  the  intra-ureteral  ligament,  extends  between  the  ori- 
fices of  the  ureters. 

The  dimensions  of  the  vesical  triangle  are  subject  to 
individual  variations.  The  triangle  is  usually  equilateral, 
its  sides  varying  from  i  to  i^^  inches  in  length.  The 
vesical  orifices  of  the  ureters  are  therefore  situated  at 
points  lying  from  ^  to  ^  of  an  inch  from  the  median 
line — a  useful  fact  to  remember  in  opening  the  bladder 
through  the  vagina. 

The  vascular  supply  of  the  bladder  is  intimately  asso- 
ciated with  that  of  the  uterus — a  fact  that  explains  the 
sympathetic  disturbance  of  the  bladder  in  uterine  dis- 
ease. The  interior  of  the  normal  bladder  is  of  a  dull 
gray-red  color.  When  distended,  as  in  making  an  endo- 
scopic examination,  the  minute  arteries  and  veins  may 
be  plainly  seen  upon  the  surface. 

The  pressure  of  the  urine  in  the  bladder  may  be  deter- 
mined by  the  manometer.  In  the  erect  posture  the  intra- 
vesical pressure  has  been  found  to  vary  from  12  to  16 
inches  of  mercury.  In  the  recumbent  posture  the  pres- 
sure is  reduced  to  from  4  to  6  inches. 

Cystitis. — Cystitis,  especially  of  the  subacute  or  the 
chronic  form,  is  a  common  disease  in  women.  The 
pathological  changes  resemble  those  seen  in  inflamma- 
tion of  mucous  membrane  in  other  parts  of  the  body. 

In  the  acute  stage  the  mucous  membrane  is  swollen 
and  relaxed,  and  of  a  deep-red  or  hyperemic  appearance. 


430     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Partial   exfoliation   takes   place.     The    surface   may   be 
covered  with  thick,  tenacious  mucus  or  pus. 

In  the  chronic  stage  the  mucous  membrane  is  of  a 
muddy  gray  color,  and  may  be  more  or  less  covered  with 
a  muco-purulent  secretion.  Ulceration,  superficial  or 
deep,  may  occur.  The  ulcer  is  sometimes  deep  and 
ragged  and  extends  into  the  muscular  wall. 

In  chronic  cystitis  we  often  find  on  the  surface  of  the 
mucous  membrane  small  localized  areas  of  inflammation 
varying  in  size  from  yi  inch  to  2  inches  in  diameter,  and 
presenting  a  congested,  granular,  or  eroded  appearance, 
while  the  rest  of  the  mucous  membrane  appears  perfectly 
normal.  These  areas  of  inflammation  bleed  readily  when 
touched.  They  are  most  often  found  in  the  base  of  the 
bladder,  though  they  may  occur  in  any  part.  When 
chronic  cystitis  is  limited,  it  is  usually  confined  to  the 
vesical  triangle. 

The  outer  coats  of  the  bladder  may  be  involved  in  the 
inflammatory  process,  and  become  much  thickened  and 
hypertrophied.  The  ureters  and  the  kidneys  may  be- 
come in  time  affected,  through  direct  extension  of  the 
inflammation  in  the  form  of  a  ureteritis  and  pyelitis,  or 
through  obstruction  of  the  vesical  orifice  of  the  ureters 
from  inflammatory  thickening.  The  alteration  in  the 
character  of  the  urine  is  usually  marked  except  in  the 
mild  forms  of  chronic  inflammation.  The  specific  grav- 
ity is  low,  varying  from  1005  to  1018.  In  the  chronic' 
disease  the  urine  is  alkaline  and  ammoniacal.  It  con- 
tains blood,  mucus,  pus,  and  epithelial  cells  from  the 
vesical  mucosa. 

Cystitis  in  women  is  usually  caused  by  infection  at 
catheterization.  The  very  great  improvement  in  the 
asepsis  of  this  procedure  that  has  taken  place  in  recent 
years  has  in  a  corresponding  degree  diminished  the  fre- 
quency of  cystitis. 

Infection  at  catheterization  is  caused  not  only  by  the 
use  of  a  dirty  catheter,  but  by  the  conveyance  of  septic 
material  from  the  external  genitals  or  the  urethra  into 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    431 

the  bladder.  For  this  reason  the  nurse  or  the  physician 
should  never  pass  the  catheter  by  touch,  as  was  some- 
times formerly  taught.  The  parts  should  be  exposed  to 
view,  and  the  external  genitals,  vestibule,  and  meatus 
should  be  cleansed. 

Cystitis  may  also  be  caused  by  extension  of  urethritis; 
by  inflammation  of  adjacent  organs;  by  abnormal  urine; 
by  constitutional  diseases,  as  the  exanthemata;  by  in- 
juries to  the  bladder  and  displacement  of  this  organ; 
and  by  retention  of  urine. 

Symptoms. — The  symptoms  of  cystitis  vary  with  the 
stage  and  the  character  of  the  affection.  Pain,  frequent 
urination,  and  tenesmus  are  usually  present. 

In  the  acute  stages  there  may  be  an  elevation  of 
temperature.  There  is  a  feeling  of  fulness  in  the 
bladder,  with  pain  in  the  region  of  this  organ.  The 
pain  is  increased  by  motion  and  by  the  erect  position, 
which  increases  the  intra-vesical  pressure.  The  pain 
is  constant,  and  is  not  relieved  by  evacuation  of  the 
bladder.  Pressure  upon  the  base  of  the  bladder  through 
the  vagina  causes  pain.  This  is  a  useful  diagnostic  point. 
There  is  a  frequent  desire  to  urinate,  and  the  passage  of 
urine  is  followed  by  straining  efforts  or  tenesmus.  The 
alteration  in  the  character  of  the  urine  has  already  been 
mentioned. 

In  time  the  general  system  suffers  from  secondary  renal 
disease  and  from  absorption,  through  the  bladder,  of  the 
ingredients  of  decomposed  urine  and  septic  material  from 
the  mucous  membrane. 

The  diagnosis  of  cystitis  is  easily  made  by  proper  ex- 
amination. It  should  always  be  remembered  that  not 
every  woman  who  complains  of  painful  and  frequent 
urination  and  vesical  tenesmus  is  necessarily  suffering 
with  cystitis.  These  symptoms  are  often  caused  by  dis- 
ease of  the  urethra,  by  displacement  of  the  uterus,  which 
drags  upon  the  neck  of  the  bladder,  by  the  pressure  of  a 
tumor,  or  by  displacement  of  the  bladder  such  as  may 
follow  laceration  of  the  perineum. 


432      A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Women  may  often  be  seen  who  have  been  treated  for 
weeks  for  cystitis  without  avail,  and  who  are  immediately 
relieved  of  all  symptoms  by  the  replacement  of  a  retro- 
verted  uterus  or  the  closure  of  a  torn  perineum.  These 
'conditions  may  in  time  result  in  cystitis,  but  the  disease 
usually  disappears  with  the  cure  of  the  causative  lesion. 

It  is  of  the  first  importance,  therefore,  for  the  physician 
to  make  a  careful  pelvic  examination,  and  to  exclude  all 
conditions  that  might  cause  irritation  of  the  bladder. 
Microscopic  examination  of  the  urine,  by  revealing  the 
presence  of  pus  and  blood  and  the  epithelial  cells  of  the 
bladder,  is  of  value  in  making  a  diagnosis.  The  urine 
for  examination  should  be  drawn  with  the  catheter,  to 
prevent  contamination  from  vaginal  discharges. 

Examination  of  the  urine  does  not,  as  a  rule,  enable 
one  to  exclude  inflammation  of  the  ureters  or  of  the  pel- 
ves of  the  kidneys.  If  there  is  any  doubt,  it  may  be  re- 
moved by  the  use  of  the  endoscope,  which  will  reveal  the 
true  condition  of  the  bladder-wall. 

As  has  already  been  said,  tenderness  upon  pressure 
through  the  vagina  on  the  base  of  the  bladder  is  of  diag- 
nostic value  in  determining  the  presence  of  cystitis.  In 
the  mild  forms  of  chronic  cystitis — those  characterized  by 
local  areas  of  inflammation — examination  of  the  urine 
may  throw  no  light  upon  the  condition,  as  the  secretion 
of  pus  or  mucus  is  very  slight.  The  diagnosis  can  then 
be  made  only  by  means  of  the  endoscope. 

It  is  perhaps  advisable  in  all  cases  of  chronic  cystitis  to 
use  the  endoscope,  not  only  to  confirm  the  diagnosis,  but 
to  begin  the  treatment  by  making  direct  local  applica- 
tions. 

Treatment. — The  treatment  of  cystitis  is  general  and 
local.  Local  treatment  should  never  be  used  in  the  acute 
stages  of  the  disease.  Many  cases  recover  completely 
without  any  local  treatment  whatever. 

In  acute  cystitis  the  wornan  should  be  put  to  bed.  The 
irritation  of  the  bladder  is  much  relieved  when  the  intra- 
vesical pressure  is  thus  diminished. 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    433 

The  diet  should  be  carefully  regulated,  all  stimulating 
ingredients  being  withdrawn.  An  exclusive  milk  diet  is 
the  best. 

Saline  laxatives  should  be  administered,  and  continued 
to  the  point  of  mild  purgation.  One  dram  of  Rochelle 
salts  every  two  or  three  hours,  given  in  half  a  tumbler- 
ful of  soda-water,  is  useful  for  this  purpose.  Large 
quantities  of  diluent  drinks  should  be  given,  such  as  flax- 
seed tea  or  Vichy  water. 

If  the  urine  is  acid,  citrate  of  potassium  may  be  ad- 
ministered with  the  diluent  drinks,  so  that  from  i  to  2 
drams  of  the  salt  are  taken  during  the  day.  Bicarbonate 
of  potassium  in  similar  doses  is  also  useful. 

When  the  urine  becomes  ammoniacal,  boracic  acid,  in 
doses  of  10  grains  from  three  to  six  times  a  day,  is  most 
useful.  Benzoic  acid,  in  doses  of  10  grains  three  or  four 
times  a  day,  is  also  valuable. 

A  very  good  method  is  to  make  a  pint  or  a  quart  of 
flaxseed  tea,  to  dissolve  in  it  the  requisite  amount  of 
citrate  of  potassium  or  of  boracic  acid  (as  the  urine  is 
acid  or  alkaline),  and  to  administer  this  in  divided  doses 
during  the  day.  This  treatment,  with  rest  in  bed,  should 
be  continued  as  long  as  the  vesical  pain  and  tenesmus 
continue. 

If  the  pain  and  tenesmus  are  severe,  small  doses  of 
opium  may  be  given.  It  is,  however,  not  advisable  to 
use  opium  unless  the  suffering  of  the  woman  demands  it. 

If  the  disease,  as  the  symptoms  become  less  acute,  does 
not  progress  satisfactorily  toward  cure,  medicines  that 
have  a  more  stimulating  effect  upon  the  mucous  mem- 
brane should  be  given,  such  as  cubebs  and  copaiba,  oil 
of  turpentine,  oil  of  eucalyptus,  and  oil  of  sandalwood. 

Many  cases  of  acute  cystitis,  if  carefully  treated  in  this 
way,  will  recover  completely  without  the  use  of  local 
treatment.  If,  however,  the  disease  does  not  yield  to 
these  measures,  local  treatment  becomes  necessary. 

In  many  instances  the  woman  first  comes  under  treat- 
ment when  the  disease  has  reached  a  chronic  stage;  or  it 

28 


434     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

may  be  that  the  disease  has  begun  subacutely,  and  has 
gradually  progressed  without  having  presented  any 
symptoms  of  acute  onset.  lyocal  combined  with  gene- 
ral treatment  is  then  often  advisable  from  the  beginning. 
Local  treatment  consists  of  general  applications  made 
to  the  whole  of  the  interior  of  the  bladder  through  the 
catheter;  direct  application,  limited  to  the  diseased  por- 


FlG.  191. — Apparatus  for  washing  the  bladder. 

tions  of  the  mucous  membrane,  through  the  endoscope; 
and  operation,  or  the  formation  of  a  vesico- vaginal  fistula. 

Washing  out  the  bladder  with  sterile  warm  water, 
either  pure  or  medicated,  is  often  very  useful.  Gentle- 
ness in  manipulation  and  asepsis  should  be  carefully  ob- 
served in  this  procedure,  or  much  more  harm  than  good 
may  result  from  it.  The  operation,  if  properly  performed, 
should  never  give  pain  to  the  woman. 

A  very  simple  apparatus  is   required,  consisting  of  a 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    435 

soft-rubber  catheter,  of  moderate  size,  attached  to  a  small 
glass  funnel  by  means  of  a  rubber  tube  and  a  piece  of 
glass  tubing.     The  whole  is  about  2  feet  long  (Fig.  191). 

The  catheter,  slightly  lubricated  at  the  point,  should 
be  gently  introduced  into  the  bladder,  and  the  urine 
should  be  slowly  withdrawn.  As  the  urine  flows,  into  the 
funnel  its  character  may  be  observed.  The  rapidity  of 
the  flow  of  the  urine  may  be  regulated  by  raising  or  low- 
ering the  funnel.  As  the  last  portion  of  the  urine  is 
withdrawn  the  flow  should  be  very  slow,  in  order  to  pre- 
vent injury  to  the  vesical  mucous  membrane  from  drag- 
ging it  into  the  eye  of  the  catheter. 

When  the  bladder  is  emptied,  sterile  hot  water  may  be 
introduced  through  the  funnel  and  the  process  of  with- 
drawal repeated.  The  mucus,  pus,  or  blood  which  had 
remained  in  the  bladder  after  evacuating  the  urine  may 
be  examined  as  the  water  flows  into  the  funnel.  This 
process  may  be  repeated  several  times  if  necessary  to 
wash  out  the  bladder.  The  water  should  be  about  the 
temperature  of  the  body  (100°  F.).  It  is  less  irritating 
to  the  mucous  membrane  if  there  is  dissolved  in  it  boracic 
acid  or  common  table  salt,  about  i  dram  to  the  pint. 

The  quantity  of  water  introduced  into  the  bladder  may 
be  regulated  by  the  feelings  of  the  patient.  The  disten- 
tion of  the  bladder  should  never  be  great  enough  to  cause 
pain.  Usually  an  ounce  of  fluid  is  all  that  can  at  first 
be  tolerated  without  producing  pain.  As  improvement 
takes  place  more  fluid  may  be  introduced  in  the  subse- 
quent treatments. 

After  the  bladder  has  been  washed  out  in  this  way, 
applications  may  be  made  to  the  interior  by  pouring 
through  the  funnel  the  desired  medicated  solution,  the 
most  useful  one  being  a  weak  solution  of  nitrate  of  silver 
(gr.  j  or  ij  to  .?j).  This  solution  should  be  retained  in  the 
bladder  for  a  few  minutes,  and  should  then  be  withdrawn. 

A  solution  of  sulphate  of  copper  (gr.  j-iv  to  sj)  is  also 
useful. 

At  first  daily  irrigation  and  application  should  be  thus 


436     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

practised.  As  the  case  improves  the  intervals  between 
the  treatments  should  be  lengthened. 

This  local  treatment  should  always  be  combined  with 
the  general  treatment  already  prescribed — rest  in  bed  if 
possible,  a  milk  diet,  and  the  administration  of  boracic 
acid  internally. 

Application  through  the  Endoscope. — If  the  endoscope 
is  used  in  the  first  place  for  diagnosis  in  a  case  of  chronic 
cystitis,  much  time  that  might  otherwise  be  wasted  in 
unnecessary  or  useless  forms  of  treatment  may  be  saved. 
The  condition  of  the  parts  may  be  accurately  determined, 
and  the  proper  form  of  treatment  may  be  instituted.  It 
may,  for  instance,  be  seen  that  deep  ulceration  is  present, 
or  that  other  lesions  of  the  bladder  are  so  extensive  that 
the  quickest  plan  of  cure  will  be  to  proceed  immediately 
to  the  formation  of  a  vesico-vaginal  fistula,  without  at- 
tempting to  treat  the  disease  by  applications. 

Applications  may  be  readily  made  through  the  endo- 
scope to  any  part  of  the  interior  of  the  bladder.  Appli- 
cations made  in  this  wa}^  are  most  useful  when  the  dis- 
ease is  localized.  Stronger  solutions  may  be  used  on  the 
affected  areas  than  when  the  application  is  made  to  the 
whole  surface  of  the  organ. 

When  the  disease  is  limited  to  the  vesical  triangle  or 
to  local  areas  situated  elsewhere,  the  inflamed  spots 
should  be  touched  with  a  solution  of  nitrate  of  silver 
(gr.  v-xx  to  .^j).  Much  benefit  is  frequently  derived  from 
one  such  application,  in  connection  with  the  general 
treatment  already  indicated.  The  applications  may  be 
made  every  few  days.  The  procedure  causes  less  discom- 
fort to  the  woman  as  she  becomes  accustomed  to  it. 

Cystotomy. — In  cases  of  ulceration  of  the  mucous  mem- 
brane, or  when  the  disease  has  resisted  the  milder  forms 
of  treatment,  it  may  become  necessary  to  perform  cystot- 
omy, to  furnish  an  opening  for  the  continuous  drain  of 
the  urine,  and  to  put  the  bladder  at  rest  by  relieving  it 
from  all  functional  action.  This  is  a  most  valuable  thera- 
peutic operation  in  cases  of  obstinate  cystitis. 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    437 

In  performing  cystotomy  the  anatomical  relations  of 
the  ureters  and  the  internal  orifice  of  the  urethra  must 
be  kept  in  mind.  It  will  be  remembered  that  the  ureters 
terminate  in  the  bladder  at  points  situated  from  }4  to  }^ 
of  an  inch  from  the  median  line. 

The  course  of  the  urethra  is  indicated  by  the  anterior 
vaginal  column,  which  is  a  single  or  double  thickening 


Fig.  192. — Illustration  of  the  position  of  the  incision  in  vaginal  cystotomy, 
and  the  relations  of  the  urethra  and  the  ureters  :  ^,  anterior  vaginal  column ; 
jB  marks  the  position  of  the  internal  urinary  meatus ;  C  and  D  mark  the  orifices 
of  the  ureters.  The  distance  from  C  to  D  varies  from  i  to  l^  inches.  C,  £,  D 
is  approximately  an  equilateral  triangle. 


of  mucous  membrane  traversed  by  short  transverse  folds 
or  ridges.  It  begins  near  the  external  meatus  and  extends 
upward  for  about  an  inch.  The  internal  meatus  may  be 
very  approximately  located  by  the  upper  end  of  this  an- 
terior vaginal  column.  The  incision  into  the  bladder 
should  be  made  in  the  median  line  above  this  point. 

The  operation  should  be  performed  under  the  influence 
of  an  anesthetic.  The  woman  should  be  placed  in  the 
Sims  or  the  dorso-sacral  position.     The  anterior  vaginal 


438     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

wall  should  be  exposed  with  the  Sims  speculum.  A 
sound  should  be  passed  into  the  bladder,  and  its  point 
should  be  pressed  against  the  posterior  vesical  wall 
toward  the  vagina,  at  the  position  where  the  incision  is 
to  be  made.  The  incision  should  be  made  into  the  blad- 
der through  the  tissues  fixed  on  the  point  of  the  sound. 
The  opening  may  then-  be  enlarged  with  the  knife  or 
scissors.  The  opening  should  be  from  i  to  i  ^  inches  in 
length.  In  order  to  prevent  spontaneous  closure  of  the 
fistula,  the  mucous  membrane  of  the  bladder  should  be 
sutured  to  the  mucous  membrane  of  the  urethra  around 
the  margin  of  the  fistula. 

The  after-treatment  consists  in  daily  washing  of  the 
bladder  with  large  quantities  of  sterile  warm  water  or 
with  the  boracic-acid  solution.  The  woman  should  be 
placed  in  the  dorso-sacral  position,  and  the  fistulous  open- 
ing should  be  exposed  by  the  Sims  speculum.  The  water 
should  be  introduced  into  the  bladder  through  the  ure- 
thra. Care  must  be  taken  to  hold  the  edges  of  the  fistula 
open,  so  that  there  may  be  a  free  channel  of  escape. 

The  patient  should  at  first  remain  in  bed.  After  the 
acute  symptoms  have  disappeared  she  may  get  up  and 
the  frequency  of  the  local  treatments  may  be  diminished. 
Various  appliances  have  been  introduced  for  receiving 
the  continuously  escaping  urine.  None  of  them,  how- 
ever, are  satisfactory.  They  are  difiicult  to  keep  clean, 
they  cause  pain,  and  they  are  liable  to  become  displaced. 
The  best  method  is  to  wear  a  vulvar  pad  of  some  absorb- 
ent material  and  to  pay  strict  attention  to  cleanliness. 
The  progress  of  the  case  may  be  determined  by  exami- 
nation of  the  urine,  and  by  examination  of  the  vesical 
mucous  membrane  through  the  fistula  or  through  the 
endoscope. 

The  time  required  for  cure  may  extend  from  one  to  six 
months. 

When  the  vesical  membrane  has  been  restored  to  a 
normal  condition  the  fistula  may  be  readily  closed. 

Vesical  Calculus. — Stone  in  the  bladder  is  less  com- 


DISEASES  OF  THE  URETHRA  AND  BLADDER.    439 

mon  among  women  than  among  men.  This  fact  is  prob- 
ably due  to  the  greater  size  and  dilatability  of  the  female 
urethra,  on  account  of  which  small  calculi  may  readily 
pass  out. 

The  symptoms  and  methods  of  diagnosis  of  vesical 
calculus  are  similar  to  those  in  the  male.  The  stone 
may  often  be  palpated  by  bimanual  examination. 

Treatment. — Small  stones  uncomplicated  with  cystitis 
may  be  crushed  and  removed  through  the  urethra.  Large 
stones  should  be  removed  by  cystotomy.  Whenever 
cystitis  is  present,  it  is  advisable  to  perform  cystotomy 
and  to  make  a  permanent  fistula  until  the  cystitis  is 
cured,  when  the  opening  may  be  readily  closed. 


CHAPTER  XXXVIII. 
GONORRHEA    IN     WOMEN. 

Gonorrhea  in  women  has  been  considered  discon- 
nectedly in  the  preceding  pages  as  one  of  several  patho- 
logical conditions  that  affect  the  different  parts  of  the 
genital  tract.  A  more  connected  discussion  of  the  sub- 
ject will  be  of  value,  in  view  of  the  frequency  of  the 
disease,  its  often  unsuspected  or  insidious  character,  and 
the  serious  and  fatal  lesions  that  it  may  produce.  Lying 
between  the  two  specialties  of  venereal  diseases  and  gyne- 
cology, it  is  often  ignored  or  slighted  by  both. 

Acute  gonorrhea  in  the  female  is  much  less  frequent 
than  in  the  male.  It  is  rare  in  the  gynecological  dispen- 
saries of  Philadelphia  to  see  acute  gonorrhea  of  any 
part  of  the  genito-urinary  tract. 

The  disease  is  very  often  subacute  or  chronic  from  the 
beginning,  and  is  not,  as  in  the  male,  always  preceded 
by  a  period  of  acute  invasion,  the  symptoms  of  which 
necessarily  attract  the  attention  of  the  patient  and  the 
physician.  For  this  reason  gonorrhea  in  the  woman  is 
very  often  overlooked.  We  can  as  yet  form  no  accurate 
estimate  of  its  frequency.  Certain  lesions,  such  as  pyo- 
salpinx,  which  may  be  the  remote  result  of  gonorrhea, 
are  often,  especially  by  gynecologists,  indiscriminately 
attributed  to  this  disease  without  anything  like  sufficient 
evidence  of  such  a  causative  relation. 

The  fact  that  the  husband  may  at  some  time  of  his 
life  have  had  gonorrhea,  or  even  that  the  woman  may 
have  had  gonorrhea,  is  no  evidence  that  a  pyosalpinx 
that  appears  in  "later  years  has  been  caused  by  this  dis- 
ease. There  are  many  other  causes  of  pyosalpinx  be- 
sides gonorrhea.     The  frequent  causative  relation  of  sep- 

440 


GONORRHEA  IN  WOMEN.  441 

sis  at  labor,  miscarriage,  or  criminal  abortion,  or  during 
the  intra-uterine  manipulations  of  the  physician,  should 
always  be  remembered. 

I  have  no  intention  of  underrating  the  danger  to  the 
woman  of  coitus  with  a  man  who  is  not  entirely  cured 
of  a  gonorrhea  or  a  gleet.  The  lives  of  a  great  many 
women  have  been  ruined  by  marriage  with  incompletely 
cured  gonorrheal  husbands,  and  but  very  few  men  in  such 
a  condition  would  contemplate  marriage  if  they  were 
aware  of  the  danger  to  the  woman  that  results  from  such 
an  act.  But,  on  the  other  hand,  men  who  are  at  all  care- 
ful of  themselves  are,  without  doubt,  usually  completely 
cured  of  gonorrhea;  and  there  are  thousands  of  men  in 
the  community  who  have  had  one  or  more  attacks  of 
gonorrhea  before  marriage,  and  who  have  now  healthy 
and  prolific  wives.  Every  physician  of  experience  will 
find  such  examples  in  the  circle  of  his  own  practice  or 
acquaintance.  It  is  very  unscientific  to  lay  the  responsi- 
bility upon  such  husbands  for  every  pelvic  inflammatory 
condition  that  may  appear  in  their  wives. 

The  difficulty  of  proving  the  presence  of  gonorrhea  in 
women  is  often  very  great.  As  has  been  said,  the  disease 
may  begin  and  may  exist  for  a  long  time  without  attract- 
ing the  attention  of  the  woman.  She  often  pays  no  at- 
tention to  a  slight  burning  or  tickling  sensation  in  the 
urethra,  which  passes  off  in  a  few  days.  She  may  have 
had  a  leucorrheal  discharge  for  a  long  time,  and  she  may 
fail  to  notice  any  slight  alteration  in  its  character  or  quan- 
tity that  may  have  been  caused  by  gonorrhea. 

There  is  nothing  in  the  gross  appearance  of  the  dis- 
charge from  any  part  of  the  genital  tract  which  is  abso- 
lutely pathognomonic  of  gonorrhea.  The  condition  may 
be  suspected  if  there  is  a  purulent  discharge  from  the 
urethra,  because  urethritis  in  women  is  very  generally  of 
gonorrheal  origin.  But,  on  the  other  hand,  there  may  be 
an  innocent-looking  mucous  discharge  from  the  cervix, 
such  as  occurs  in  health  or  in  mild  non-specific  condi- 
tions, yet  in  which  gonococci  may  be  found. 


442      A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  presence  of  the  gonococcus  is,  of  course,  positive 
evidence  of  gonorrhea.  But  this  organism  may  be  pres- 
ent in  small  numbers  and  escape  detection  even  at  the 
hands  of  experienced  observers;  or  it  may  be  present  in 
the  tissues  of  the  infected  region  and  fail  to  appear  in 
the  discharge;  or  it  may  in  time  itself  disappear  alto- 
gether. And  thus,  when  the  woman  begins  to  suffer  from 
some  of  the  remote  lesions  of  gonorrhea,  such  as  an  en- 
dometritis or  a  salpingitis,  and  is  driven  to  seek  medical 
advice,  she  may  be  unable  to  give  an}^  history  whatever 
of  the  beginning  of  the  disease;  the  character  of  the 
secretions  may  teach  the  physician  nothing;  the  gono- 
coccus may  have  disappeared  from  the  genital  discharge; 
and  though  a  pyosalpinx  may  be  present  which  had 
originally  been  caused  by  gonorrhea,  yet  the  gonococcus 
may  likewise  have  disappeared  from  the  tubal  pus,  and 
other  pathogenic  organisms  may  be  found  in  its  place. 
It  becomes  impossible  to  determine  the  true  origin  of  the 
disease. 

For  these  reasons,  if  the  physician  is  accurate  in  his 
observations,  and  classifies  as  gonorrheal  only  those  cases 
the  specific  origin  of  which  he  can  prove,  the  frequency 
of  gonorrheal  lesions  in  women  will  be  considerably 
understated. 

Sanger  states  that  in  about  one-eighth  of  all  gyneco- 
logical diseases  gonorrhea  is  the  underlying  cause.  Tay- 
lor, viewing  the  condition  from  the  side  of  the  venereal 
specialist,  says  that  this  statement  is  conservative  and 
probably  nearly  correct. 

It  must  be  borne  in  mind  that  gonorrhea  is  sometimes 
caused  in  other  ways  than  by  coitus.  This  is  seen  in  the 
epidemics  of  gonorrhea  that  occur  in  children.  It  is  with- 
out doubt  sometimes  caused  by  the  use  of  an  infected 
vaginal  syringe.  Cases  of  rectal  gonorrhea  are  not  infre- 
quently thus  produced. 

Gonorrhea  in  women  may  attack  any  part  of  the  gen- 
ito-urinary  tract.  It  rarely  attacks  a  number  of  struc- 
tures at  one  time,  but  it  usually  becomes  localized  in  one 


GONORRHEA  IN  WOMEN.  '  443 

or  two  parts,  such  as  the  urethra,  the  glands  of  the  ves- 
tibule, the  vulvo-vaginal  glands,  the  vaginal  fornices,  or 
the  cervix  uteri,  and  runs  a  subacute  course,  and  may  re- 
main quiescent  for  a  long  period.  It  may  in  time  dis- 
appear spontaneously,  or  it  may  be  excited  into  activity 
by  a  variety  of  causes,  such  as  traumatism,  unusual 
coitus,  labor,  or  miscarriage.  The  parts  of  the  genito- 
urinary apparatus  that  are  covered  by  pavement  epithe- 
lium are  much  more  resistant  to  the  gonococcus  than  are 
the  parts  covered  with  cylindrical  epithelium.  For  this 
reason  the  external  genital  surface  and  the  vagina  of  the 
woman,  and  the  vaginal  aspect  of  the  cervix,  are  often 
exempt  when  other  less  resistant  structures  are  attacked. 

Gonorrhea  attacks  the  different  parts  in  the  following 
order  of  frequency:  the  urethra,  the  cervix  uteri,  the 
vulva,   and  the  vagina. 

Gonorrhea  of  the  urethra  is  the  most  common  form  of 
the  disease.  The  great  majority  of  the  cases  of  urethritis 
in  women  are  of  gonorrheal  origin.  Whenever  there  is 
a  purulent  or  muco-purulent  discharge  from  the  urethra 
gonorrhea  should  be  suspected,  whether  or  not  the  gono- 
coccus is  found  in  it. 

The  disease  may  linger  in  the  mucous  glands  found 
near  the  external  meatus  and  in  Skene's  glands  for  a  long 
time.  The  symptoms  of  this  condition  have  already  been 
considered.  The  disease  may  present  all  the  phenomena 
of  acute  urethritis  in  the  male,  or  it  may  be  subacute 
from  the  beginning. 

Gonorrhea  of  the  cei^vix  uteri  occurs  next  in  frequency. 
As  far  as  the  few  accurate  observations  that  have  been 
made  teach  us  anything,  gonorrhea  of  the  cervix  is  but 
little  less  frequent  than  gonorrhea  of  the  urethra.  The 
disease  may  exist  in  conjunction  with  gonorrhea  of  some 
other  part,  or  it  may  occur  alone.  The  infection  takes 
place  directly  from  the  discharge  of  the  penis  which 
comes  in  contact  with  the  external  os.  Gonorrhea  of 
the  cervix  usually  begins  in  a  subacute  or  an  insidious 
manner.     It    is   usually  unattended   by  any  general    or 


444     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

local  symptoms  sufficiently  marked  to  attract  attention. 
If  the  woman  had  been  free  from  a  leucorrheal  discharge, 
she  may  observe  a  muco-purulent  secretion  caused  by  the 
gonorrhea.  If  she  had  a  leucorrhea,  the  alteration  in 
the  character  and  amount  of  the  discharge  is  usually 
not  sufficient  to  attract  her  attention.  In  some  cases  the 
discharge  becomes  more  purulent  in  character;  in  others 
there  is  no  alteration  perceptible  to  the  naked  eye. 

If  the  disease  runs  an  acute  course,  the  appearance  of 
the  cervix  will  be  that  characteristic  of  acute  inflamma- 
tion. The  vaginal  cervix  is  congested;  the  external  os 
is  patulous  and  is  surrounded  by  a  red  granular  or  eroded 
area,  while  from  it  is  seen  escaping  a  purulent  discharge. 

Pelvic  pain  or  discomfort  is  not  usually  present  unless 
the  body  of  the  uterus  is  attacked. 

All  the  symptoms  of  gonorrheal  inflammation  of  the 
cervix  are  found  in  simple  non-specific  conditions.  The 
only  certain  diagnosis  is  made  by  means  of  the  micro- 
scope; and  even  failure  to  find  the  gonococcus  will  not 
enable  the  physician  to  say  with  certainty  that  the  dis- 
ease is  not  of  gonorrheal  origin.  The  gonococcus  may 
be  found  in  any  form  of  discharge  from  the  cervix,  even 
that  which  to  gross  examination  appears  most  innocent. 

Consequently,  in  every  suspected  case  a  microscopic 
examination  should  be  made. 

The  discharge,  for  examination,  should  be  taken  from 
the  cavity  of  the  cervix  by  means  of  a  sterile  platinum 
loop.  If  no  gonococci  are  found,  a  strip  of  mucous 
membrane  from  the  cervical  canal  should  be  removed 
with  a  sharp  curette,  and  it,  with  the  discharge  that  ad- 
heres to  it,  should  be  carefully  examined. 

It  may  be  advisable  to  examine  the  discharge  immedi- 
ately after  menstruation,  A  cervical  discharge  is  always 
increased  immediately  before,  during,  and  after  a  men- 
strual period.  This  is  probably  the  reason  that  men  are 
more  liable  to  contract  gonorrhea  at  that  time.  This  fact 
is  so  well  known  that  there  is  a  widespread  popular  be- 
lief that  gonorrhea  may  be  acquired  from  coitus,  during 


GONORRHEA  IN  WOMEN.  445 

a  menstrual  period,  with  a  healthy  woman.  This  is  not 
true.  A  man  cannot  acquire  gonorrhea  from  a  woman 
unless  she  had  been  previously  infected  with  the  disease; 
otherwise  a  woman  might  develop  gonorrhea  in  herself 
spontaneously,  for  her  discharges  come  in  contact  with 
her  own  genito-urinary  tract. 

The  greater  liability  to  infection  at  the  time  of  men- 
struation is  due  to  the  fact  that  an  existing  pathological 
discharge  is  increased  in  amount;  a  subacute  disease  is 
rendered  more  active  by  the  menstrual  congestion;  and 
gonococci,  quiescent  in  the  superficial  cells,  are  more 
likely  to  be  thrown  off  at  this  time. 

Gonorrhea  of  the  cervix  very  often  stops  at  the  internal 
OS.  It  may,  however,  extend  to  the  body  of  the  uterus 
and  to  the  Fallopian  tubes,  as  has  already  been  described. 
The  diagnosis  of  gonorrheal  endometritis  can  be  made 
only  by  microscopic  examination  of  the  discharge  or  of 
a  strip  of  the  endometrium  removed  with  the  curette. 

The  gonorrheal  discharge  of  the  cervix  may  infect, 
secondarily,  local  areas  of  the  vagina.  The  most  usual 
position  of  secondary  infection  is  the  posterior  vaginal 
fornix.  A  red  eroded  area,  caused  in  this  way,  is  often 
found.  The  prolonged  contact  of  the  pus  produces  a 
localized  vaginal  gonorrhea. 

Primary  vaginal  gonorrhea  is  rare  in  the  adult  woman, 
in  whom  there  is  the  usual  resistant  power  of  the  epithe- 
lium. The  mucous  membrane  of  the  vagina  becomes 
tough  from  coitus  and  childbirth,  and  is  usually  impreg- 
nable to  the  gonococcus.  Bumm  has  kept  gonorrheal 
pus  in  contact  with  the  vaginal  wall  for  twelve  hours 
without  producing  any  inflammatory  reaction. 

In  girls  and  in  young  women,  in  whom  the  mucous 
membrane  of  the  vagina  is  soft  and  hyperemic,  vaginal 
gonorrhea  is  more  likely  to  occur.  Like  gonorrhea  in 
other  parts,  the  disease  may  be  acute  or  chronic.  It  may 
involve  the  whole  vaginal  tract  or  it  may  be  restricted  to 
local  areas. 

The  disease  sometimes  involves  only  the  lower  portion 


446      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

of  the  vagina,  and  is  most  severe  on  the  posterior  wall. 
In  other  cases  it  is  limited  to  the  posterior  vaginal  fornix, 
where  it  has  a  tendency  to  become  localized  and  to  persist. 
In  the  very  early  stage  the  mucous  membrane  is  dry  and 
red.  It  later  becomes  covered  with  a  purulent  or  muco- 
purulent secretion  of  a  milky  color. 

If  the  disease  is  extensive,  severe  symptoms  may  be 
present.  The  woman  will  suffer  with  burning  pain  in 
the  pelvis,  the  pain  being  increased  by  any  movement. 

Acute  inflammation  of  the  vagina  is  usually  of  gonor- 
rheal origin.  A  thorough  examination  of  the  condition 
can  be  made  only  by  placing  the  woman  in  the  knee- 
chest  position  and  by  exposing  the  vagina  by  retracting 
the  perineum  with  the  Sims  speculum.  The  whole  vag- 
inal tube,  especially  the  posterior  wall  near  the  ostium 
and  the  fornices,  should  be  carefully  inspected. 

Gonorrhea  of  the  znilva  may  arise  primarily,  or  it  may 
be  caused  by  infection  from  discharge  from  the  vagina  or 
the  cervix.  Like  gonorrhea  of  the  vagina,  it  is  rare  in 
the  adult  woman.  It  is  usually  seen  in  girls  or  in  young 
women.  Its  occurrence  in  children  has  already  been 
referred  to. 

The  disease  may  extend  to  the  small  glands  of  the 
vestibule  and  the  fourchette  and  to  Bartholini's  glands; 
in  these  situations  it  may  lurk  for  many  years,  forming  a 
source  of  infection  to  men  and  a  great  element  of  danger 
to  the  woman.  Suppuration  of  the  glands  of  the  vesti- 
bule may  result  in  small  urethral  fistulse. 

In  making  an  examination  of  the  external  genitals  the 
parts  should  always  be  thoroughly  exposed  and  the  phy- 
sician should  attempt  to  express  the  fluid  from  the  orifices 
of  the  glands.  Microscopic  examination  of  the  dis- 
charge should  be  made. 

Inflammation  of  any  of  the  glands  of  the  external  gen- 
itals is  usually  the  result  of  gonorrhea. 

When  the  physician  examines  a  woman  suspected  of 
gonorrhea,  she  should  not  prepare  herself  beforehand  by 
vaginal  douches  and  washing  the  external  genitals.     The 


GONORRHEA  IN  WOMEN.  447 

urine  should  not  have  been  voided  for  some  time.  Pros- 
titutes, fearing  that  gonorrhea  will  be  discovered,  often 
remove  all  discharges  as  much  as  possible  before  they 
submit  to  examination.  Other  women  do  the  same  from 
motives  of  cleanliness.  As  the  diagnoiBis  depends  upon 
observation  of  the  origin  and  character  of  the  discharges, 
such  preparation  should  be  avoided. 

As  has  already  been  said,  it  may  be  advisable  in  doubt- 
ful cases  to  make  the  examination  immediately  after  a 
menstrual  period,  when  the  discharges  are  more  profuse 
and  perhaps  more  virulent  than  at  other  times.  The  ex- 
aminer should  always  proceed  methodically,  and  should 
inspect  every  portion  of  the  external  genitals,  the  vagina, 
and  the  cervix.  The  vestibule,  the  external  meatus,  the 
urethra,  the  fourchette,  the  glands  of  Bartholini,  the 
vaginal  walls,  the  external  os,  and  the  cervical  canal 
should  in  turn  be  examined.  Discharges  obtained  from 
these  structures  should  be  saved  and  submitted  to  micro- 
scopic examination. 

Though  the  gonococcus  is  by  no  means  always  found 
in  cases  the  specific  character  of  which  is  proved  by  in- 
fection of  the  man,  yet  it  would  escape  observation  much 
less  often  if  such  thorough  examination  were  made. 

If  the  gonococcus  is  not  found,  the  diagnosis  must  be 
made  from  the  consideration  of  the  lesions  that  we  know 
occur  but  rarely  except  in  gonorrhea.  Thus,  urethritis 
is  a  strong  diagnostic  point  in  favor  of  gonorrhea;  so  is 
inflammation  of  the  glands  of  the  vestibule,  of  the  four- 
chette, and  of  the  vulvo-vaginal  glands.  Vaginitis  not 
caused  by  the  degenerations  of  old  age,  by  traumatism, 
or  by  the  discharge  from  a  cancer  of  the  cervix  or  from  a 
vesico-vaginal  fistula  is  usually  of  gonorrheal  origin. 
This  is  especially  true  of  vaginitis  localized  in  the  vag- 
inal fornices. 

Gonorrhea  in  women  should  be  most  carefully  treated 
until  all  signs  of  the  disease  are  eradicated.  The  treat- 
ment has  already  been  discussed  under  the  consideration 
of  the  different  structures  that  may  be  attacked.     Gonor- 


448      A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

rheal  cervicitis  and  endometritis  are  the  most  difficult  to 
cure,  and  it  may  be  impossible  to  determine  with  cer- 
tainty that  the  disease  has  been  eradicated  from  these 
structures.  If  milder  measures  fail,  the  cervical  canal 
and  the  body  of  the  uterus  should  be  completely  curetted, 
and  the  raw  surface  should  be  treated  with  pure  carbolic 
acid.  The  physician  should  never  discharge  the  patient 
until  she  is  thoroughly  cured. 


CHAPTER  XXXIX. 
THE  TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS. 

The  technique  of  some  of  the  special  gynecological 
operations,  such  as  perineorrhaphy,  and  trachelorrhaphy, 
has  already  been  considered  in  discussing  the  treatment 
of  the  conditions  in  which  such  operations  are  applicable. 
The  general  and  local  preparation  of  the  patient,  the 
instruments,  the  dressings,  etc.,  and  the  technique  of  the 
general  operations  of  gynecology  that  are  applicable  to  a 
variety  of  different  pathological  conditions,  such  as  ooph- 
orectomy and  hysterectomy,  now  demand  consideration. 
The  general  rules  of  asepsis  that  are  followed  in  gyne- 
cological operations  are  the  same  as  those  that  should  be 
observed  in  all  surgical  operations.  And  although  every 
surgeon  should  strive  to  attain  perfect  asepsis  in  all  ope- 
rations, yet  it  is  of  especial  importance  for  the  gynecolo- 
gist to  do  so,  for  he,  more  often  than  all  others,  invades 
the  peritoneal  cavity.  Of  the  various  structures  of  the 
body,  the  peritoneum  is  one  of  the  most  susceptible  to 
septic  influences;  and  septic  infection  of  the  peritoneum, 
unlike  infection  of  other  structures,  implies  not  merely 
a  local  disturbance  and  delay  of  healing,  but  general 
sepsis  and  death. 

Moreover,  the  gynecologist,  operating  in  the  perito- 
neum, cannot  correct  any  imperfection  in  his  aseptic 
technique  by  the  use  of  antiseptic  solutions,  as  can  be 
done  in  other  operations  of  general  surgery.  Such  anti- 
septic solutions,  if  of  sufficient  strength  to  be  of  any  value 
as  germicides,  are  very  dangerous  in  the  peritoneum. 
They  may  produce  fatal  poisoning  from  absorption 
through  the  peritoneum ;  they  destroy  the  delicate  peri- 
toneal surface,  and  thus  diminish  the  very  useful  power 

29  449 


450     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

of  the  peritoneum  to  absorb  blood  and  serum  after  the 
operation;  they  cause  intestinal  and  other  adhesions;  and 
they  so  impair  the  integrity  of  the  intestinal  walls  that 
septic  organisms  may  be  enabled  to  pass  through  and 
infect  the  general  peritoneum. 

The  gynecologist,  thus  debarred  from  the  use  of  anti- 
septics during  a  peritoneal  operation,  must  rely  altogether 
upon  the  perfection  of  his  aseptic  technique. 

It  must  not  be  forgotten  that  the  danger  of  peritoneal 
infection,  though  very  much  less  in  the  minor  gyneco- 
logical operations  on  the  perineum  and  the  cervix,  is  yet 
never  altogether  absent.  The  whole  genital  tract  of 
women  communicates  directly  with  the  peritoneum,  and 
infection  at  any  point  may  extend  and  cause  fatal  peri- 
toneal sepsis. 

The  danger  increases  with  the  proximity  of  the  in- 
fected point  to  the  peritoneum.  The  danger  of  salpin- 
gitis and  peritonitis  from  trivial  intra-uterine  manipula- 
tions not  performed  aseptically,  such  as  the  passage  of  a 
dirty  sound,  has  already  been  referred  to.  Fatal  perito- 
nitis has  followed  trachelorrhaphy. 

In  the  various  plastic  operations  of  gynecology  disas- 
trous results  are,  of  course,  not  so  likely  to  occur  from 
imperfect  asepsis  as  in  those  operations  that  involve 
opening  the  peritoneum.  In  some  of  these  operations, 
such  as  closure  of  a  vesico-vaginal  or  a  recto-vaginal  fis- 
tula, it  is  impossible  to  obtain  perfect  asepsis. 

In  minor  gynecological  operations,  however,  we  may 
use  antiseptic  solutions  which  are  inadmissible  within 
the  peritoneum;  and  the  vascularity  of  the  genital  tract 
is  so  great  that  healing  is  usually  rapid  and  perfect  even 
with  very  imperfect  asepsis.  This  fact,  however,  should 
never  justify  carelessness  on  the  part  of  the  physician. 
In  every  surgical  procedure,  however  trivial,  the  strictest 
asepsis  should  always  be  observed.  The  practice  avoids, 
at  any  rate,  a  minimum  danger;  it  is  a  useful  training 
for  the  physician;  and  it  sets  a  valuable  example  to  the 
assistants  and  nurses.     No  part  of  the  technique  should 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  451 

be  ''good  enough."     It  should  be  as  good  as  it  can  be 
made. 

The  greatest  factor  in  the  success  of  modern  gyne- 
cology has  been  asepsis.  The  doctrine  has  become  so 
widely  spread  that  the  technique,  and  consequently  the 
results,  of  careless  operators  of  the  present  day  are  much 
better  than  those  of  the  best  operators  before  the  days  of 
Ivisterism. 

This  is  not  said  to  justify  carelessness.     No  woman 
should  at  operation  be  exposed  to  any  dangers  not  in- 
separable from  her   condition.     The   assistants   and  the 
nurses  should  be  especially  made  to  feel  the  responsibility 
of  their  positions.     A  careless  nurse  or  assistant  may  in- 
troduce sepsis   and  cause  death  after  the  most  skilfully 
performed  operation.     Unfortunately,  there  is  not  a  dis- 
tinct realization  of  this  fact.     An  assistant,  though  con- 
scious of  some  carelessness  of  his  own,  usually  beguiles 
himself  with  the  belief  that  death  was  due  to  some^'other 
cause.     If  there  were  a  distinct  realization  of  personal 
responsibility  among  all  concerned  at  an  operation,  death 
from  infection  through  carelessness  would  be  avoided  as 
are   other  kinds"  of    manslaughter.      Unless   a   surgeon 
knows  that  he  can  furnish  the  proper  aseptic  conditions, 
he  has  no  right  to  advise  a  patient  to  submit  to  operation 
unless  the  disease  is  such  that  operation  is  demanded 
tinder  any  circumstances. 

At  the  present  day  the  gynecologist  advises  a  woman 
to  submit  to  a  serious— potentially  fatal— operation,  like 
celiotomy,  for  the  relief  of  many  conditions  which  cause 
suffering,  but  which  do  not  cause  death.  He  does  this 
conscientiously,  because  he  knows  that  if  the  operation 
is  properly  performed  the  danger  to  life  is  very  small. 
If  he  is  not  certain  that  the  proper  operative  conditions 
will  be  at  hand,  he  cannot  conscientiously  give  this  ad- 
vice, and  he  had  better  follow  some  palliative  treatment. 
Operations  are  always  better  done  in  a  well-equipped 
operating-room  than  in  a  private  house.  In  the  opera- 
ting-room we  have  better  asepsis,   better  light  and  me- 


452      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

chanical  appliances,  better  discipline  of  assistants  and 
nurses,  and  greater  opportunity  of  successfully  dealing 
with  unexpected  complications. 

In  an  operation  which  is  performed  in  a  private  house 
something  is  always  used  which  is  more  or  less  of  a 
makeshift;  and  makeshifts  should  not  be  used  in  surgery, 
especially  in  abdominal  surgery.  If  we  hope  to  obtain 
perfect  results,  we  must  insist  upon  perfect  surroundings 
and  appliances.  Continuous  success  is  the  result  of 
scientific  accuracy  and  attention'  to  detail.  I  say  con- 
tinuous success,  because  this  is  the  only  test  of  good 
surgery.  We  should  not  be  misled  by  occasional  bril- 
liant results  obtained  under  imperfect  conditions.  In 
such  circumstances  the  operator  admits  to  himself  that 
his  patient  was  lucky.  The  element  of  luck  should 
be  entirely  eliminated.  Nothing  should  be  trusted  to 
luck. 

Fortunately,  most  of  the  operations  of  gynecology  are 
performed  for  conditions  of  such  a  character  that  there  is 
no  demand  for  instant  operation.  The  woman  can  usu- 
ally wait  until  suitable  conditions  are  furnished.  In 
cases  of  emergency  the  surgeon  can  only  do  his  best 
under  the  existing  circumstances,  not  his  best  under  the 
best  circumstances. 

It  cannot  be  denied  that  good  results,  as  far  as  mortal- 
ity is  concerned,  are  obtained  in  abdominal  operations  in 
private  houses.  The  mortality,  however,  for  a  long 
series  of  cases  of  all  kinds  is  greater  than  that  obtained 
in  well-equipped  hospitals  by  operators  of  equal  ability. 
The  number  of  incomplete  and  imperfectly  performed 
operations  is  much  greater  in  private  houses  than  in  the 
hospital,  for  the  operator  with  imperfect  surroundings 
fears  to  deal  radically  with  some  unexpected  conditions 
which  he  meets,  and  is  satisfied  if  the  woman's  life  is 
saved,   though  she  be  not  perfectly  cured. 

It  is  not  necessary  to  dwell  upon  the  need  of  proper 
training  of  the  operator  himself  in  abdominal  surgery. 
The  minor  gynecological  operations  may  be  performed 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  453 
by  any  one  who  is  familiar  with  the  ordinary  principles 
of  surgery  and  who  understands  the  special  technique  of 
the  operation.     There  is  no  fear  of  unexpected  complica- 

ions  in  such  operations.  Rapidity  of  work  is  not  essen- 
tial,  as  m  abdominal  surgery,  and  the  operator  may  study 
the  condition  as  he  proceeds;  moreover,  errors  arisino- 
from  inexperience  or  ignorance  are  not  attended  by  fatal 
results.  ^ 

In  abdominal  surgery,  however,  the  operator  should  be 
specially  trained  for  the  work.  Except  in  cases  of 
emergency,  he  should  not  perform  these  operations  un- 
ess  he  expects  to  do  so  continuously.  He  should  be 
trained  by  work  upon  the  cadaver  and  the  lower  animals 
and  by  watching  and  assisting  experienced  operators. 
He  should  be  prepared  to  deal,  without  hesitation,  with 
every  pathological  condition  that  may  be  met  with  in 
the  abdomen;  a  glance  at  works  on  abdominal  surgery 
will  show  how  numerous  such  conditions  are 

A  few  successes  in  simple  cases  in  the  hands  of  an  in- 
competent operator  will  lure  him  on  with  false  confidence 
until  he  finally  meets  a  condition  with  which  he  is  unable 
to  cope.  Either  the  patient  dies  as  a  result,  or,  if  the  op- 
erator be  conservative,  the  abdomen  is  closed  over  an  in- 
complete  operation. 

_  The  directions  which  are  about  to  be  given  apply  espe- 
cially to  those  operations  in  which  the  peritoneal  cavity 
IS  entered.  They  may  be  modified  in  obvious  particulars 
m  case  a  minor  operation  is  to  be  performed  upon  the 
vagina  or  the  uterus.  In  such  cases  special  abdominal 
Cleansing  is  unnecessary  and  complete  evacuation  of  the 
intestinal  tract  is  not  so  important. 

The  technique  described  is  that  which  is  followed  by  the 
writer.  Various  equally  good  modifications  are  employed 
by  other  operators.  It  seems  best,  however,  to  give  but 
one  rigid  method  which  experience  has  proved  success- 
ful. The  experienced  operator  is  able  to  change  it  ac- 
cording to  his  individual  preferences 
Operating-room.-The    operating-room     should    be 


454     ^   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

well  lighted  from  the  top  and  at  least  one  side.  If  a  good 
natural  light  cannot  be  secured,  an  electric  drop-light 
will  be  found  very  convenient.  For  work  deep  in  the 
pelvis  or  the  abdomen  a  good  light  is  essential.  If  neces- 
sary, light  may  be  directed  to  the  desired  point  by  means 
of  the  ordinary  head-mirror. 

The  floor,  walls,  and  ceiling  of  the  room  should  be  of 
some  non-absorbing  material.  There  should  be  in  the 
room  no  appliances  whatever  that  are  not  essential  for  the 
performance  of  the  operation. 

The  interior  of  the  room  should  be  wiped  throughout 
with  a  mop  or  with  wet  cloths,  or,  still  better,  flushed 
with  the  hose,  in  order  to  remove  and  lay  all  dust.  The 
room  may  be  wiped  throughout  with  a  solution  of  bi- 
chloride of  mercury  (i  :  2000). 

The  temperature  of  the  room  should  be  not  less  than 
75°  F.  Shock  from  bodily  loss  of  heat  and  exposure  of 
the  peritoneum  is  diminished  if  the  atmosphere  of  the 
room  is  at  an  elevated  temperature. 

Apparatus. — All  apparatus,  such  as  basins,  tables, 
etc.,  should  be  of  such  a  character  that  it  may  be  steril- 
ized by  boiling  or  by  washing  with  a  solution  of  bichloride 
of  mercury  (i  :  1000).  Glass-top  tables  with  painted  or 
nickel-plated  frames  are  preferable.  The  operating-table 
should  be  so  arranged  that  the  patient  may  be  placed  in 
the  Trendelenburg  position  (Fig.  193).  This  position 
permits  the  intestines  to  gravitate  out  of  the  pelvis,  and 
is  very  useful  in  many  operations.  There  are  a  great 
variety  of  tables  in  use.  Before  the  Trendelenburg  pos- 
ture was  introduced  the  writer  used  for  several  years  a 
plain  hard-wood  plank  supported  by  two  wooden  horses. 
The  Boldt  table  is  very  convenient.  With  it  there  is  no 
necessity  for  a  rubber  pad  for  catching  fluids.  It  is  ap- 
plicable for  all  gynecological  operations.  Some  operators 
are  in  the  habit  of  dressing  the  operating  table  by  placing 
on  it  a  blanket  and  sheet.  This  is  unnecessary,  unless 
the  patient  is  in  such  a  condition  of  collapse  that  it  is 
essential  to  preserve  all  bodily  heat.     The  blanket  usu- 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  455 

ally  becomes  saturated  with  fluids   and  serves  no  good 
purpose. 

The  number  and  arrangement  of  the  basins,  tables, 
stands,  etc.  used  in  an  abdominal  operation  are  shown  in 
Fig.  194. 

The  basins  are  best  sterilized  by  boiling,  or  by  wash- 
ing with  scalding  water  (inside  and  outside)  and  a  solu- 
tion of  bichloride  of  mercury  (i  :  1000). 

The  tables  and  stands  are  sterilized  by  washing  with 
the  bichloride  solution.     If  wooden-top  tables  are  used. 


Fig.  193 — Trendelenburg  position. 

they  should  be  covered  with  a  towel  wrung  out  of  a 
I  :  1000  bichloride  solution. 

Operator,  Assistants,  Nurses.— Usually  one  assist- 
ant, who  stands  opposite  the  operator,  and  two  nurses,  are 
sufficient.  A  second  assistant,  standing  beside  the  ope- 
rator, is  useful  to  thread  needles  and  to  hand  instruments 
and  ligatures.  The  operator,  assistants,  and  nurses 
should  possess  such  general  cleanliness  as  follows  a 
morning  bath.  They  should  not  attend  any  patients 
suffering  with  a  septic  or  infections  condition  upon  the 
day  of  the  operation.  If  they  have  done  so  upon  the 
previous  day,   they  should  subsequently  take  a  general 


456     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  457 

bath  and  change  all  clothing.  Care  in  this  respect  is 
especially  desirable  on  the  part  of  the  nurses,  whose  long 
hair  prevents  easy  cleansing  of  the  head. 

The  operator  and  assistants  should  wear  sterilized  outer 
clothes — cotton  shirt  and  duck  trousers.  A  large  steril- 
ized apron  put  on  immediately  before  the  operation  is  an 
additional  protection.  The  nurses  should  wear  large 
sterilized  aprons  over  freshly  washed,  if  not  sterilized, 
dresses. 

The  hands  and  forearms  of  the  operator,  assistants,  and 
nurses  should  be  bare  and  especially  sterilized.  The 
finger-nails  should  be  short,  rounded,  and  smooth.  A 
long  nail  is  difficult  to  clean,  and  in  the  case  of  the  ope- 
rator is  dangerous,  as  it  may  lacerate  important  structures 
in  the  process  of  enucleation  of  a  tumor.  Enucleation 
of  adherent  growths  is  best  done  with  the  blunt  finger, 
which  passes  along  the  planes  of  separation.  The  sharp 
nail  may  perforate  an  intestine  or  lacerate  a  blood-vessel, 
instead  of  pushing  it  aside. 

The  nails,  fingers,  hands,  forearms,  and  lower  part  of 
the  upper  arms  should  be  thoroughly  scrubbed  with  fre- 
quently changed  hot  water  and  soap  (preferably  soft  soap) 
and  a  large  stiff  nail-brush.  The  process  should  not  be 
done  hastily  or  but  once.  The  soap  should  be  repeatedly 
washed  off  and  renewed.  Five  minutes,  at  least,  should  be 
devoted  to  the  scrubbing.  The  hands  and  arms  should  then 
be  similarly  scrubbed  with  alcohol,  and  finally  scrubbed 
with  a  solution  of  bichloride  of  mercury  i  :  1000.  Im- 
mediately before  proceeding  with  the  operation  the  hands 
and  arms  should  be  rinsed  in  sterile  water. 

There  should  be  a  nail-brush  for  each  solution  used. 
The  brushes  should  be  clean  and  sterilized  by  boiling 
or  by  placing  in  the  steam  sterilizer. 

After  sterilizing  the  hands,  the  operator,  the  assistants, 
and  nurses  should  touch  nothing  which  is  not  sterile.  If 
they  are  obliged  to  do  so,  the  hands  should  be  again 
washed. 

Rubber  gloves,  such  as  are  used  in  general  surgery,  are 


458      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

very  useful  in  the  operations  of  gynecology.  They  may 
be  worn  to  protect  the  patient  in  case  the  operator  or  the 
assistants  are  not  certain  of  the  sterility  of  their  hands, 
or  to  protect  the  operator  when  working  upon  a  septic 
patient. 

Sterilisation  of  Dressings,  Towels,  etc. — The  ope- 
rating-cloths, aprons,  sheets,  towels,  dressings,  gauze 
pads,  etc.  are  most  conveniently  sterilized  by  steam  heat. 
The  temperature  should  be  at  least  ioo°  C.  (212°  F.). 
The  dressings  and  bandages  should  not  be  too  tightly 
packed,  so  that  all  parts  may  be  exposed  to  the  same 
temperature. 

Several  kinds  of  steam  sterilizers  have  been  introduced. 
The  most  easily  obtained  is  the  Arnold  sterilizer.  An 
apparatus  like  the  Sprague  sterilizer,  in  which  the  steam 
is  superheated,  is  preferable,  but,  as  it  is  not  portable,  it 
is  adapted  only  for  hospital  use. 

The  dressings  should  be  maintained  at  the  elevated 
temperature  for  an  hour  or  more.  Although  this  method 
secures  very  good  sterilization,  yet  there  are  certain  spores 
which  resist  such  elevated  temperature  even  after  a  two 
hours'  exposure.  The  method  of  fractional  or  discon- 
tinuous sterilization  has  therefore  been  introduced.  Two 
or  three  successive  sterilizations  are  practised  at  inter- 
vals of  twenty-four  hours.  Spores  which  at  first  escape 
destruction  will  have  developed  into  vegetative  forms  in 
the  intervals,  and  are  destroyed  by  the  final  sterilizations. 

At  the  Gynecean  Hospital  all  dressings  are  sterilized 
for  three  consecutive  days  for  two  hours  each  day.  The 
dressings,  towels,  etc.,  after  sterilization,  should  be  pre- 
served in  sterile  glass  jars  or  other  sterile  receptacle. 

Steriliijation  of  Instruments. — Instruments,  drain- 
age-tubes, catheters,  and  any  rubber  appliance  may  be 
sterilized  by  boiling  in  water  for  fifteen  to  thirty  min- 
utes. A  dilute  solution  (i  per  cent.)  of  carbonate  of 
soda  is  preferable,  as  the  instruments  are  not  so  easily 
rusted,  and  this  solution,  when  boiling,  has  greater  germi- 
cidal qualities  than  plain  water. 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  459 

Very  convenient  instniment-sterilizers  are  made,  in 
which  the  instruments  are  contained  in  a  tray  that  may 
be  lifted  out  and  placed  in  the  receptacle  for  containing 
the  instruments  during  the  operation.  This  receptacle  or 
pan  should  itself  be  sterilized,  and  should  contain  sterile 
water,  or  preferably  the  sterile  solution  of  bicarbonate  of 
soda,  in  sufficient  quantity  to  cover  the  instruments. 

It  is  very  convenient  to  keep  on  hand  a  saturated  solu- 
tion of  carbonate  of  soda,  sterilized  by  boiling,  a  small 
quantity  of  which  may  be  added  to  the  water  in  the  in- 
strument-tray. Rusting  of  instruments  is  diminished  by 
this  means. 

Appliances  that  are  injured  by  moist  heat  or  by  steam 
may  be  sterilized  by  thorough  washing  and  soaking  in  a 
solution  of  bichloride  of  mercury  (i  :  1000).  It  is  useful 
to  keep  a  large  vessel  of  such  a  solution  on  hand,  in 
which  apparatus  that  is  not  injured  by  the  bichloride 
may  be  placed. 

The  Water. — The  water  used  during  the  operation, 
for  washing  the  wound,  the  abdominal  cavity,  the 
sponges,  and  the  hands  of  the  operator  and  assistants, 
should  be  sterilized  by  boiling  from  fifteen  to  thirty  min- 
utes or  by  distillation.  If  the  water  contain  a  perceptible 
sediment,  it  should  first  be  filtered. 

Very  convenient  water-sterilizers  are  made,  from  which 
the  water  may  be  drawn  of  any  desired  temperature,  after 
having  been  both  filtered  and  sterilized  by  heat.  There 
should  always  be  a  large  quantity  of  sterile  hot  water  at 
hand.  Water  below  the  temperature  of  the  body  should 
not  be  introduced  in  the  peritoneal  cavity,  and  pads 
brought  in  contact  with  the  intestines  should  be  wrung 
out  of  hot  water. 

About  fifteen  gallons  of  sterile  water  are  usually  re- 
quired in  an  abdominal  operation. 

The  water  should  be  preserved  in  sterile  pitchers, 
basins,   or  other  receptacles. 

Glass  flasks  are  very  convenient  for  containing  the  water 
with  which  the  abdomen  or  pelvis  may  be  washed  out. 


46o     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  water  may  be  poured  directly  into  the  abdomen  from 
the  flask.  The  flask  should  be  plugged  with  non-absorb- 
ent cotton  to  prevent  the  entrance  of  dust. 

Some  operators  prefer  to  use  a  normal  salt  solution 
(sodium  chloride  gr.  90  to  water  sxxxiiiss)  for  washing 
out  the  peritoneum.  Such  a  solution  is  probably  less 
irritating  to  the  peritoneum  than  plain  water. 

If  the  flasks  are  used  for  containing  the  water,  it  may 
be  boiled  in  them,  and  then  preserved  by  plugging  with 
absorbent  cotton  until  required  at  the  operation.  The 
temperature  of  the  water  used  for  abdominal  irrigation 
should  be  100°  to  115°  F. 

Sponges. — In  the  minor  operations  about  the  vagina 
or  uterus  the  field  of  operation  may  be  kept  clean  by 
irrigation  with  sterile  water  or  by  the  use  of  sponges. 
Small  sponges  in  holders  are  commonly  used.  These 
sponges,  after  being  washed  free  of  sand  and  bleached  if 
necessary,  may  be  sterilized  by  soaking  for  twelve  hours 
in  a  solution  of  bichloride  of  mercury  (i  :  500).  They 
should  then  be  rinsed  in  warm  water  and  preserved  in  a 
3  per  cent,  watery  solution  of  carbolic  acid,  which  should 
be  changed  every  week. 

Artificial  sponges,  or  gauze  sponges,  are  the  most  con- 
venient in  abdominal  surgery.  They  are  cheap,  and  may 
be  destroyed  after  each  operation,  and  they  are  very 
easily  and  certainly  sterilized  in  the  steam  sterilizer. 
Good  marine  sponges  are  so  expensive  that  but  few  ope- 
rators destroy  them  after  they  have  been  once  used.  The 
cleansing  and  sterilization  of  such  sponges  are  tedious 
and  uncertain. 

The  gauze  sponges  answer  every  purpose.  The  writer 
has  used  gauze  sponges  exclusively  in  several  hundred  ab- 
dominal operations  performed  during  the  last  three  years. 

The  gauze  sponges  may  be  made  of  various  sizes  by 
sewing  together  about  eighteen  layers  of  plain  absorbent 
gauze.  The  edges  of  the  gauze  should  be  folded  in  and 
hemmed  to  prevent  the  escape  of  loose  threads  in  the 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  461 

peritoneum.  Some  operators  use  sponges  made  by  wrap- 
ping absorbent  cotton  somewhat  loosely  in  gauze. 

The  number  of  sponges  used  should  always  be  recorded 
before  the  operation.  It  is  advisable  to  preserve  the 
sponges  in  sets  always  of  the  same  number,  so  that  in 
every  case  the  operator  knows  that  this  number,  or  some 
multiple  of  this  number,  of  sponges  has  been  used.  The 
writer  uses  such  sets  of  seven  gauze  sponges  of  the  fol- 
lowing sizes:  one  sponge  3  by  3  inches;  one  sponge  10 
by  7  inches;  five  sponges  5  by  5  inches.  Usually  one 
such  set  of  sponges  is  enough  for  an  abdominal  opera- 
tion. In  some  cases,  however,  the  first  set  of  sponges 
may  become  soiled  by  the  discharge  from  an  abscess  or  a 
suppurating  tumor,  and  it  is  advisable  to  discard  these 
sponges  and  to  complete  the  operation  with  a  second 
clean  set. 

The  number  of  sponges  should  never  be  altered  during 
an  operation  by  cutting  one  in  two. 

Sponges  should  never  be  removed  from  the  operating- 
room  until  the  abdomen  has  been  closed  and  the  sponges 
have  been  counted.  If  a  sponge  falls  on  the  floor  or  in 
the  vessel  to  receive  slops,  it  should  be  put  aside  until 
the  final  counting  is  completed. 

When  a  set  of  sponges  is  used,  they  should  always  be 
carefully  counted  as  they  are  placed  in  the  basin,  for  the 
nurse  who  prepared  and  put  up  the  set  may  have  care- 
lessly miscounted  them. 

Accuracy  in  regard  to  the  sponges  is  of  the  greatest 
importance.  There  are  a  number  of  recorded  cases,  and 
many  unrecorded,  in  which  sponges  have  been  left  in 
the  abdomen.  This  accident  is  usually  fatal,  though 
there  are  several  cases  on  record  in  which  the  sponge  has 
made  its  way,  by  ulceration,  into  the  intestine,  and  has 
been  discharged  from  the  anus,  or  has  been  removed  by 
subsequent  incision  through  the  abdominal  wall. 

Discipline  of  the  Operating-room. — The  discipline 
of  the  operating-room  should  be  most  rigid.  Perfect 
personal    asepsis   can   be   obtained   only   by   continuous 


462      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

watching  and  criticism.  The  work  should  be  syste- 
matically divided  among  the  assistants  and  nurses,  and 
each  should  attend  strictly  to  his  or  her  own  department, 
and  to  nothing  else. 

The  first  assistant  should  assist  the  operator  with 
sponges,  etc.  The  second  assistant  should  attend  to  the 
instruments,  ligatures,  and  sutures.  The  first  nurse 
should  wash  the  sponges  and  place  them  in  a  basin  of 
sterile  water  beside  the  first  assistant.  She  should  also 
attend  to  the  towels  and  dressings.  The  second  nurse, 
under  direction  of  the  first,  should  change  soiled  water 
in  the  sponge-  and  hand-basins,  etc. 

No  one  should  pick  up  anything  that  may  have  been 
dropped  upon  the  floor,  and  no  one,  unless  it  is  abso- 
lutely necessary,  should  touch  anything  that  has  not 
been  sterilized. 

Anesthesia. — With  the  exception  of  the  operator,  the 
anesthetizer  is  the  most  important  person  at  an  abdom- 
inal operation.  A  careful,  experienced  anesthetizer  is 
desirable  in  all  operations,  but  especially  so  in  an  abdom- 
inal operation.  Much  more  depends  upon  him  than  upon 
the  assistant.  The  custom  of  trusting;  the  anesthesia  to 
the  least  experienced  man  is  reprehensible.  Many  fatal 
cases  after  celiotomy  may  be  attributed  directly  to  the 
anesthesia. 

Every  operator  of  experience  has  observed  the  differ- 
ence in  reaction  between  those  patients  who  have  been 
carefully  anesthetized  and  those  who  have  been  improp- 
erly anesthetized.  In  a  serious  case  attended  by  unavoid- 
able shock  the  superadded  depression  of  ether-poisoning 
may  be  enough  to  cause  a  fatal  result. 

The  operator  should  have  nothing  to  do  with  the  anes- 
thesia, and  it  should  not  be  necessary  for  him  to  watch  it. 
The  anesthetizer  should  make  a  careful  examination  of 
the  heart,  and  should  be  provided  with  a  hypodermic 
syringe  and  the  necessary  stimulants,  which  he  should 
use  at  his  own  discretion. 

He  should,    of   course,  use  the  minimum  amount  of 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  463 

ether.  He  should  be  familiar  with  the  steps  of  the  ope- 
ration, and  he  should  so  regulate  the  anesthesia  that  the 
operator  will  not  be  impeded  by  the  straining  or  struggles 
of  the  patient  at  critical  moments. 

Preparation  of  the  Patient. — It  is  always  desirable, 
when  possible,  to  have  the  patient  under  observation  for 
several  days  before  operation.  As  I  have  already  said,  a 
more  accurate  diagnosis  may  be  made  by  repeated  exam- 
inations, and  opportunity  is  afforded  for  the  administra- 
tion of  medicines  to  improve  the  general  condition.  A 
weak  woman  about  to  submit  to  a  serious  operation  is 
benefited  by  the  administration  of  -^-^  grain  of  strychnine 
three  times  a  day,  for  several  days  before  the  operation. 

During  this  period  the  patient  should  receive  a  daily 
bath,  a  laxative  when  necessary  to  produce  a  daily  move- 
ment, and  a  vaginal  douche  of  one  gallon  of  hot  water 
every  morning  and  evening. 

The  special  preparation  of  the  patient  is  directed  to 
sterilizing  the  abdominal  surface,  the  external  genitals, 
and  the  vagina,  and  to  emptying  the  gastro-intestinal 
tract.  This  preparation  should  begin  twenty-four  hours 
before  the  operation.  During  this  time  it  is  best  to  con- 
fine the  patient  to  bed. 

Thorough  evacuation  of  the  intestinal  tract  is  very  de- 
sirable in  abdominal  surgery.  When  the  intestines  are 
empty  and  collapsed,  the  various  intra-abdominal  manip- 
ulations are  most  easily  performed.  If  the  intestine  is 
injured  and  it  becomes  necessary  to  repair  it,  or  if  any 
other  intestinal  operation  is  required,  it  may  be  performed 
most  easily  and  with  the  greatest  cleanliness  if  the  gut  is 
empty. 

Though  it  is  impossible  to  sterilize  the  intestinal  tract, 
yet  we  most  nearly  approach  the  condition  of  sterilization 
by  thorough  evacuation  of  the  bowels. 

Twenty-four  hours  before  the  operation  purgation 
should  be  begun  by  the  administration  of  i  dram  of 
Rochelle  salts,  dissolved  in  half  a  tumblerful  of  water 
or  soda-water,  every  hour  until  the  bowels  begin  to  move 


464     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

freely.  Five  or  six  doses  are  usually  sufficient.  The 
lower  bowel  should  finally  be  emptied  thoroughly  by  an 
enema  of  soap  and  water  administered  three  or  four  hours 
before  operation.  During  the  twenty-four  hours  preced- 
ing operation  the  diet  should  consist  of  light,  easily 
digested,  concentrated  nourishment,  such  as  milk,  butter- 
milk, soft-boiled  eggs,  rare  beef,  soups,  beef-tea,  coffee, 
tea,  and  whiskey  if  necessary. 

UnlCvSS  the  patient  is  very  weak,  no  food  should  be 
given  on  the  morning  of  the  operation.  If  her  condi- 
tion does  not  warrant  such  abstinence,  she  may  have  a 
glass  of  milk,  buttermilk,  coffee,  or  milk-punch.  Such 
food  is  required  if  the  operation  is  performed  late  in  the 
day. 

In  very  feeble  patients  a  nutrient  enema  may  be  ad- 
ministered about  two  hours  before  the  operation. 

A  hypodermic  injection  of  2V  grain  of  strychnine  is 
often  useful  upon  the  morning  of  the  operation  when  the 
patient  is  in  poor  condition. 

Preparation  of  the  External  Genitals  and  Vagina. — 
The  pubis  and  the  external  genitals  should  be  shaved. 
The  woman  should  be  drawn  down  to  the  edge  of  the  bed, 
and  the  anus,  the  external  genitals,  and  the  vagina 
should  be  scrubbed  with  green  soap.  The  vagina  should 
be  washed  throughout.  The  nurse  may  do  this  by  in- 
serting one  or  two  fingers,  or  she  may  retract  the  peri- 
neum with  the  Sims  speculum,  and  scrub  the  vagina, 
the  fornices,  and  the  vaginal  cervix  with  cotton  held  in 
forceps. 

The  scrubbing  should  be  followed  by  a  vaginal  douche 
of  a  gallon  of  hot  water  to  wash  out  the  soap,  and  then 
by  a  douche  of  two  quarts  of  bichloride  solution  (i :  2000). 
One  hour  before  operation  the  vaginal  douche  of  bi- 
chloride should  be  repeated,  and  the  nurse  should  intro- 
duce in  the  vagina  as  far  as  the  cervix  a  light  vaginal 
tampon  of  gauze  wet  with  the  bichlorid  solution.  In 
every  abdominal  operation  on  women  it  is  desirable  that 
the  external  genitals  and  the  vagina  should  be  clean.     It 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  465 

may  be  necessary  to  pass  the  catheter  or  to  perform  some 
vaginal  manipulation,  or  the  vagina  may  be  opened  dur- 
ing the  operation. 

If  the  vagina  is  small  or  virginal,  or  if  the  woman  is 
nervous,  the  nurse  may  be  unable  to  perform  the  method 
of  cleansing  just  described;  and  it  is  then  necessary  for 
the  operator  or  the  assistant  to  clean  the  vagina  after  the 
woman  is  anesthetized.  Such  cleansing  should  always 
be  performed,  in  addition  to  the  cleansing  by  the  nurse, 
whenever  a  vaginal  operation  is  performed  or  it  is  ex- 
pected that  the  vagina  will  be  opened  from  above. 
Thorough  vaginal  sterilization  is  most  easily  accom- 
plished when  the  patient  is  under  the  influence  of  ether, 
as  the  perineum  is  easily  retracted  and  the  vagina  be- 
comes more  patulous.  The  woman  should  be  placed  in 
the  lithotomy  position,  and  the  washing  should  be  per- 
formed with  two  fingers  or  with  a  soft  brush  like  a 
jeweller's  brush,  or  with  cotton  in  forceps.  If  neces- 
sary, the  perineum  should  be  retracted  with  the  specu- 
lum. Green  soap  should  be  used,  and  the  vaginal  walls, 
the  fornices,  and  the  cervix  should  be  thoroughly  scrub- 
bed. The  soap  should  then  be  carefully  washed  out,  and 
the  scrubbing  should  be  repeated  with  bichloride-of-mer- 
cury  solution  (i  :  2000). 

The  cleansing  of  the  external  genitals  and  the  vagina 
is  best  done  by  the  nurse  after  the  final  movement  of  the 
bowels  and  immediately  before  the  woman  has  her  gen- 
eral bath. 

Sterilization  of  the  Abdomen. — The  patient  should  have 
a  warm  bath  from  head  to  feet  upon  the  morning  of  the 
operation.  The  abdomen,  from  the  ensiform  cartilage 
to  the  pubis,  should  be  scrubbed  with  a  nail-brush. 
Special  care  should  be  devoted  to  cleansing  the  umbili- 
cus. After  this  bath  the  patient  should  be  dressed  in  a 
clean  flannel  undershirt  and  night-gown  and  should  be 
placed  in  a  clean  bed. 

The  nurse  should  then  wash  the  abdomen,  from  the 
ensiform  cartilage  to  the  pubis  and  from  flank  to  flank,, 


466     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

and  the  upper  third  of  the  anterior  aspect  of  the  thighs, 
first  with  turpentine,  second  with  green  soap,  and  finally 
with  ether,  devoting  special  care  to  the  umbilicus.  The 
abdomen  should  then  be  covered  with  a  large  wet  bi- 
chloride dressing  (i  :  2000),  which  should  not  be  removed 
until  the  patient  is  upon  the  operating-table.     A  towel 


Fig.  195- — Tail's  hemostatic  forceps. 

wrung  out  of  the  bichloride  solution  and  held  in  place  by 
a  bandage  or  binder  will  answer  the  purpose.  A  second 
cleansing  of  the  abdomen  by  the  operator  or  the  assistant 
should  be  done  after  the  patient  is  upon  the  table.  The 
surface  should  be  washed  with  green  soap  and  sterile 


Fig.  196. — Spencer  Wells'  forceps. 


water,  then  with  ether,  and  finally  with  the  solution  of 
bichloride  of  mercury.  The  washing  should  not  be  re- 
stricted to  the  central  abdomen,  but  should  extend  over 
the  upper  parts  of  the  thighs  and  the  flanks,  which  may 
be  exposed  during  the  operation. 

The  bladder  should  be  emptied  by  the  catheter  im- 


TECHNIQUE  OF  GYNECOLOGICAL  OPERA  TIONS.  467 

mediately  before  the  patient  is  placed  upon  the  operat- 
ing-table. 

The  patient  should  be  placed  upon  the  operating-table 
by  clean  nurses  or  assistants. 

The  legs  should  be  strapped  to  the  table.  The  hands 
should  be  held  out  of  the  way  by  the  anesthetizer.  They 
may  be  retained  very  well  by  a  safety-pin  passed  through 
the  lower  sleeve  and  the  shoulder  of  the  night-gown  or 
the  pillow-case. 

The  undershirt  and  night-gown  should  be  drawn  well 
up  behind,  to  prevent  wetting.  If  the  clothes  become 
wet,  they  should  be  changed  immediately  after  operation. 
The  legs  and  the  chest  should  be  covered  with  clean 
blankets.  The  field  of  operation  should  be  surrounded  by 
sterilized  towels.  One  large  towel  with  a  hole  of  suitable 
size  in  the  center  is  convenient.  A  pocket  may  be  made 
immediately  below  the  hole,  to  retain  the  instruments 
when  the  Trendelenburg  position  is  employed. 

Instruments.— The  number  and  the  variety  of  instru- 
ments used  by  the  gynecologist  in  abdominal  operations 


Fig.  197.— Knife. 

depend  a  good  deal  upon  the  taste  of  the  individual  op- 
erator. The  list  given  here  comprises  all  the  instruments 
that  are  found  useful  by  the  writer  in  abdominal  work: 

Small  hemostatic  forceps  (Fig.  195) 12 

Medium-sized  forceps 2 

Large  forceps  (Fig.  196) 4 

Knife  (Fig.  197) .    .    .    !    i 

Scissors— two  pairs  of  long  scissors,  one  straight  and 

one  curved  on  the  flat. 

Pedicle-needles  (Fig.  198) 2 

Cyst-trocars  (Figs.  199  and  200) 2 

Straight,  spear-pointed  needles,  zyi  inches  in  length, 

for  closing  the  abdominal  incision  by  the  mass-suture. 


468     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Curved  needles  for  suturing  within  the  abdomen. 
Fine  straight  and  curved  needles  for  the  repair  of  in- 
testinal injuries. 
Large  curved  needles  for  catgut,  etc. 

Abdominal  retractors  (blunt) 2 

Needle-holder  (Fig.  201) i 

Long  dressing-forceps 2 


Three  sizes  of  twisted  silk  are  used  for  suture  and  liga- 
ture: heavy  silk  for  ligature  of  the  large  arteries;  medium 
silk  for  ligature  of  smaller  vessels  and  for  various  sutur- 
ing in  the  abdomen ;  fine  silk  for  peritoneal  and  intestinal 
suture. 


-Pedicle-needle. 


The  silk  should  be  as  small  as  is  consistent  with  secure 
ligature.  The  heavy  silk  is  necessary  for  the  ligature  of 
pedicles  in  which  a  large  amount  of  surrounding  tissue 
is  included  with  the  artery. 


Fig.  199. — Small  curved  trocar. 

The  silk  is  rolled  on  glass  spools  or  on  cores  of  gauze, 
contained  in  glass  tubes  plugged  with  cotton,  and  is  then 
sterilized  in  the  steam  sterilizer  by  fractional  steriliza- 
tion. It  is  advisable  always  to  use,  for  heavy  ligature, 
silk  of  a  uniform  size,  because  the  operator  becomes 
accustomed  to  the  strength  of  the  silk  and  knows  just 
how  much  strain  it  will  bear.  Silkworm-gut  is  the  best 
material  to  use  for  suture  of  the  abdominal  incision  in 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  469 

case  the   "  through-and-through "   or  interrupted  mass- 
suture  is  employed. 

The  silkworm-gut  should  be  of  the  heaviest  and  the 
longest  size.  It  may  be  sterilized  by  boiling  with  the 
instruments  before  the  operation. 


Fig.  200. — Large  cyst-trocar. 

Catgut  is  sometimes  employed  for  ligature  and  suture. 
The  difficulty  of  securing  certain  sterilization  makes  it 
advisable  to  avoid  using  this  material  within  the  peri- 
toneal cavity.  Sterilized  silk  is  so  certainly  absorbed  in 
all  cases  and  is  so  easily  employed  that  the  writer  has 
altogether  given  up  the  use  of  catgut  within  the  peri- 
toneum. It  is  useful  as  a  buried  suture  for  the  muscle 
and  fascia  of  the  abdominal  wall.  Silk  is  not  so  cer- 
tainly absorbed  in  this  position,  and  if  the  catgut  should 
happen  to  be  imperfectly  sterilized,  no  worse  result  than 
suppuration  of  the  incision  will  occur. 


P'iG.  201. — Reiner's  needle-holder. 

Various  methods  of  sterilizing  catgut  have  been  intro- 
duced. The  writer  uses  the  following  method,  which 
bacteriological  experiments  and  clinical  experience  have 
shown  to  be  good:  The  catgut  is  soaked  in  juniper  oil 
for  one  week.  The  oil  is  then  washed  out  with  ether 
and  the  catgut  is  soaked  in  ether  for  forty-eight  hours. 


470     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  gut  is  then  rolled  on  glass  spools  and  is  placed  in  a 
glass  jar  containing  pure  alcohol.  The  alcohol  is  boiled 
in  the  jar  for  an  hour  at  a  time  on  several  successive  days. 
The  gut  is  used  directly  from  this  jar,  and  is  always 
boiled  in  the  alcohol  for  an  hour  before  each  operation. 
In  this  way,  if  a  considerable  amount  of  gut  is  prepared 
at  one  time,  it  is  subjected  to  many  boilings  before  it  is 
used  up.  Tlie  alcohol  is  boiled  by  placing  the  glass  jar 
in  a  vessel  of  hot  water. 

The  following  methods  of  sterilizing  catgut  are  also 
good: 

Reverdiii' s  Dry-heat  Method  for  the  Sterilization  of 
Catgut. — Soak  in  ether  for  one  or  two  days.  Change  the 
ether  once.  Dry  and  roll  on  glass  reels,  place  in  test- 
tubes  covered  with  cotton,  and  place  the  tubes  in  dry-air 
oven.  In  order  not  to  burn  or  render  the  catgut  too 
friable,  the  temperature  should  be  very  slowly  elevated — 
at  least  one  hour  before  reaching  ioo°  C,  and  one  hour 
and  a  half  before  reaching  150°  C.  This  temperature 
should  be  maintained  for  two  hours;  then  the  catgut 
is  slowly  allowed  to  cool  in  the  oven.  Eight  or  nine 
hours  afterward  the  operation  must  be  repeated;  the  gut 
is  then  allowed  to  soak  for  twenty-four  hours  in  oil  of 
juniper-wood,  and  is  then  kept  in  absolute  alcohol. 

The  Cttmol  Method  for  the  Sterilisation  of  Catgnt.^  em- 
ployed at  the  Johns  Hopkins  Hospital. — i.  Cut  the  catgut 
into  the  desired  lengths,  and  roll  12  strands  in  a  figure- 
of-8  form,  so  that  it  may  be  slipped  into  a  large  test-tube. 

2.  Bring  the  catgut  gradually  up  to  a  temperature  of 
80°  C,  and  hold  it  at  this  point  for  one  hour. 

3.  Place  the  catgut  in  cumol,  which  must  not  be  above 
a  temperature  of  100°  C,  raise  it  to  165°  C,  and  hold  it 
at  this  point  for  one  hour. 

4.  Pour  off  the  cumol,  and  either  allow  the  heat  of  the 
sand-bath  to  dry  the  catgut,  or  transfer  it  to  a  hot-air 
oven,  at  a  temperature  of  100°  C.  for  two  hours. 

5.  Transfer  the  rings  with  sterile  forceps  to  test-tubes 
previously  sterilized  as  in  the  laboratory. 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  471 

/  The  cleanest  specimens  of  the  crude  catgut  should  be 
obtained  for  surgical  purposes.  There  is  no  doubt  that 
some  specimens  of  crude  catgut  are  more  difficult  to 
sterilize  than  others.  A  special  apparatus  has  been  in- 
troduced for  sterilizing  catgut  which  renders  the  process 
safe  and  certain. 

The  writer  uses  catgut  only  for  suture  of  the  abdom- 
inal fascia  and  muscles.     Large-sized  gut  is  employed. 

The  Dressing. — The  dressing  of  the  abdominal  wound 
consivSts  of  ten  or  twelve  layers  of  sterilized  gauze,  cov- 
ered by  a  large  sterilized  abdominal  pad  about  i  inch 
thick,  13  inches  long,  and  9  inches  broad.  The  pad  is 
made  of  absorbent  cotton  enclosed  in  a  layer  of  gauze. 
The  dressing  is  retained  in  place  by  a  six-tailed  sterilized 
abdominal  binder  of  flannel. 

If  no  drainage  through  the  abdominal  incision  is  em- 
ployed, the  use  of  celloidin  with  the  gauze  dressing  is  of 
advantage.  It  retains  the  dressing  securely  in  position 
for  an  indefinite  period,  and,  if  used  liberally,  it  acts  as  a 
splint  for  the  abdominal  wall.  Either  of  the  two  follow- 
ing formulae  given  by  Robb  may  be  used: 

]^.   Ether  (Squibb' s), 

Absolute  alcohol,  da.  §viss; 

Of  a  solution  made  of  15  grams  of 
bichloride  crystals  dissolved  in  11 
drams  of  absolute  alcohol,  tVLxvj. 

Mix,  and  add  of  Anthony's  "snowy  cotton"  enough 
to  give  the  solution  the  consistence  of  simple  syrup. 

^.   Absolute  alcohol,  ^  Iviss; 

Iodoform  powder,  Sxiiss; 

Mix,  and  add  ether,  Iviss. 

Mix,  and  add  of  Anthony's  "snowy  cotton"  enough 
to  give  the  solution  the  consistence  of  simple  syrup. 

The  celloidin  should  be  poured  over  the  edges  of  the 
first  layers  of  gauze  that  are  placed  upon  the  wound. 


CHAPTER    XL. 

THE  TECHNIQUE  OF   GYNECOLOGICAL  OPERATIONS 
(Continued). 

Abdominal  Drainage. — Drainage  of  the  peritoneum 
is  accomplished  by  means  of  the  glass  drainage-tube  (Fig. 
202),  or  by  capillary  drainage  with  gauze.     The  perito- 


Fig.  202. — Glass  drainage-lube. 


neum  may  be  drained  through  the  abdominal  incision  or 
through  the  vagina.  On  account  of  the  difficulty  of 
keeping  the  vagina  sterile,  drainage  through  the  abdom- 
inal incision  is  the  safer  method.  Vaginal  drainage  is 
preferred  when  the  operation  is  performed  through  the 
vagina  and  no  abdominal  incision  is  made,  as  in  the  ope- 
ration of  vaginal  hysterectomy. 

The  glass  drainage-tubes  should  be  of  various  lengths 
— 5  to  7  inches.  The  outer  diameter  should  be  about  3/^ 
or  }4  inch.  The  lower  portion  of  the  tube  is  perforated 
with  small  holes  over  a  distance  of  about  i}4  inches. 
Around  the  upper  part  or  neck  of  the  tube,  which  pro- 
trudes from  the  abdomen,  is  placed  a  square  of  rubber 
dam,  such  as  is  used  by  dentists,  about  8  by  8  inches  in 
size.  The  tube  passes  through  a  hole  in  the  center  of  the 
rubber.  The  tube  and  the  rubber  dam  may  be  sterilized 
by  boiling.  The  tube  is  usually  placed  in  the  lower  angle 
of  the  abdominal  incision,  and  the  abdominal  dressing  is 
split  so  that  it  may  be  placed  around  the  tube.  The 
bandage  is  applied  so  that  the  four  upper  tails  pass  above 
the  tube  and  the  two  lower  tails  pass  below  it     The 

472 


TECHNIQUE  OF  GYNECOEOGICAL  OPERATIONS.  473 

opening  of  the  tube  and  the  rubber  dam  are  outside  of 
the  bandage.  When  the  dressing  and  bandage  have  been 
applied,  the  opening  of  the  tube  is  plugged  with  sterile 
absorbent  cotton,  and  a  handful  of  cotton  is  placed  in  the 
dam,  which  is  then  folded  over  and  pinned.  A  sterile 
towel  is  placed  over  the  dam.  Some  operators  insert  a 
cord  of  cotton  or  a  few  narrow  strips  of  gauze  to  the 
bottom  of  the  tube,  in  order  to  maintain  a  continuous 
capillary  drain. 

Cleansing  or  emptying  the  drainage-tube  is  a  procedure 
which  should  be  very  carefully  attended  to.  Strict  asep- 
sis should  be  observed  in  all  the  manipulations.  For  the 
first  few  hours  the  general  peritoneum  is  exposed  to  dan- 
ger of  infection  every  time  the  tube  is  opened.  After 
the  first  twenty-four  hours,  though  the  danger  of  general 
peritoneal  infection  is  remote  or  absent,  yet  there  is 
always  danger  of  local  infection  of  the  tube-tract.  Such 
local  infection  may  result  in  a  persistent  sinus  or  other 
complication.  A  ligature  near  to  or  in  contact  with  the 
tube  may  become  infected,  and  the  sinus  will  remain 
open  until  the  ligature  is  discharged. 

The  tube  may  be  cleaned  by  any  careful  nurse.  The 
bedclothes  should  be  drawn  down  to  the  pubis  and  the 
clothing  should  be  drawn  up,  so  that  the  abdomen  is  ex- 
posed. Sterile  towels  should  be  placed  about  the  rubber 
dam.  The  hands  of  the  nurse  should  be  sterilized.  The 
dam  should  be  opened,  the  cotton  should  be  removed, 
and  the  orifice  of  the  tube  exposed.  The  tube  should 
be  emptied  with  the  long-nozzled  syringe  (Fig.  203),  or 


Fig.  203. — Syringe  for  cleaning  drainage-tube. 


with  some  other  easily  sterilized  apparatus  by  which  the 
fluid  may  be  withdrawn. 

All  fluid  should  be  withdrawn  from  the  drainage-tube. 
The  dam  should  be  carefully  cleansed  by  wiping  with 


474     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

cotton  wet  with  the  solution  of  bichlorid  of  mercury. 
A  fresh  cotton  plug  should  be  inserted  in  the  tube,  and 
the  dam  should  be  folded  and  pinned  over  a  handful  of 
cotton.  The  whole  should  then  be  covered  with  a  sterile 
towel. 

The  tube  should  be  emptied  or  cleaned  as  often  as  it 
becomes  filled.  It  is  often  necessary  at  first  to  clean  it 
every  fifteen,  thirty,  or  sixty  minutes.  If  free  bleeding 
is'  taking  place,  it  is  most  quickly  arrested  by  frequent 
cleaning  of  the  tube.  Unless  the  nurse  is  experienced, 
the  operator  or  assistant  should  watch  the  drainage- 
tube  for  the  first  hour  after  operation,  in  order  to  di- 
rect the  nurse  in  regard  to  the  required  frequency  of 
cleansing.  A  record  should  be  kept  of  the  amount  of 
fluid  withdrawn. 

The  intervals  between  cleansings  are  gradually  in- 
creased until  once  every  six  or  twelve  hours  becomes  suf- 
ficient. It  is  not  often  necessary  to  keep  the  tube  in  the 
abdomen  longer  than  two  or  three  days. 

The  tube  should  be  removed  when  the  fluid  discharged 
becomes  serous  in  character  and  small  in  amount — about 
one  dram  every  four  or  five  hours.  Before  removing  the 
tube  the  flannel  binder  should  be  opened  and  the  wound 
should  be  exposed.  When  the  glass  tube  is  withdrawn, 
it  is  best  to  replace  it  by  a  small  rubber  tube.  This  may 
be  done  by  inserting  the  rubber  tube  to  the  bottom  of  the 
glass  tube,  which  is  then  withdrawn.  If  we  were  certain 
that  the  tube-tract  were  aseptic,  the  introduction  of  the 
rubber  tube  would  be  unnecessary,  and  we  might  close 
the  lower  angle  of  the  incision  immediately  by  suture. 
This  procedure,  however,  may  be  followed  by  fluid-accu- 
mulation and  the  formation  of  abscess  in  the  tube-tract. 
It  is  therefore  safest  always  to  use  the  rubber  tube.  The 
rubber  tube  should  be  withdrawn  gradually,  an  inch  or  two 
every  day,  so  that  the  tract  will  close  from  the  bottom. 
In  order  to  prevent  the  rubber  tube  slipping  altogether 
into  the  drainage-tract,  it  is  advisable  to  insert  a  small 
safety-pin  through  the  extra-abdominal  end.    The  end  of 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  475 

the  rubber  tube  should  be  surrounded  and  covered  by 
several  layers  of  gauze  and  the  abdominal  pad. 

Gau^e-drainage. — Capillary  drainage  with  gauze  is 
sometimes  more  convenient  than  drainage  with  the  tube. 
A  strip,  about  2  inches  in  width,  of  several  layers  of 
gauze  should  be  carried,  from  the  part  of  the  pelvis  to  be 
drained,  out  through  the  lower  angle  of  the  abdominal 
incision.  When  the  sutures  are  introduced  the  lower 
angle  of  the  incision  should  not  be  too  tightly  closed, 
5r  drainage  will  be  impeded.  The  extra-abdominal  end 
of  the  gauze  drain  should  be  surrounded  and  covered  by 
several  layers  of  loosely-packed  gauze  and  by  the  abdom- 
inal pad  and  binder.  Sterile  cotton  should  be  tucked 
under  the  binder  immediately  above  the  pubis,  and,  if 
necessary,  around  the  upper  and  lateral  margins  of  the 
pad.  The  dressing  need  not  be  disturbed  for  one,  two, 
or  three  days,  imless  the  discharge  has  soaked  through 
the  abdominal  binder. 

A  convenient  capillary  drain  is  made  of  a  gauze  bag 
containing  several  strips  of  gauze. 

One  objection  to  the  gauze  drain  is  the  difficulty  of  re- 
moval. Lymph-processes  and  granulations  penetrate  the 
interstices  of  the  gauze,  and  often  render  its  removal  very 
difficult.  The  surgeon  fe,ars  to  use  too  much  force  in  at- 
tempts at  withdrawal,  because  an  adherent  loop  of  intes- 
tine or  the  omentum  may  be  pulled  out  of  place  or  dam- 
aged, or  the  lymph-wall  of  the  drainage-tract  may  become 
opened  and  expose  the  general  peritoneum  to  infection. 
To  avoid  this  difficulty  the  writer  has  for  some  time  em- 
ployed a  drain  made  by  surrounding  the  gauze  bag  with 
an  ordinary  rubber  condom  the  end  of  which  has  been 
cut  open  (Fig.  204).  With  this  arrangement  the  surgeon 
may  feel  certain  that  there  are  no  adhesions  except  at  the 
end  of  the  drain.  Such  drains  may  be  removed  as  easily 
as  the  glass  tube.  The  condom  may  be  sterilized  by  boil- 
ing. Gauze  drains  should  be  removed  at  the  end  of  two 
or  three  days.  After  withdrawing  the  gauze  it  is  advis- 
able to  insert  a  small  rubber  tube,  for  reasons  that  have 


476     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

been  mentioned  in  considering  the  use  of  the  glass  drain- 
age-tube. 

The  gauze  drain  may  be  used  in  all  cases  except  when 
it  is  necessary  to  drain  pus  or  some  solid  material  like 
feces.  In  such  cases  the  glass  tube  should  be  employed, 
either  alone  or  surrounded  by  a  gauze  pack  to  protect  the 
general  peritoneum. 

In  pelvic  surgery  the  drain,  whether  glass  or  gauze, 
should,  as  a  rule,  be  placed  at  the  most  dependent  part 
of  the  pelvis,  which  is  the  bottom  of  Douglas's  pouch. 


ll'.u, 


f  1 


'^W   "^^'^ 


Fig.  204.. — Gauze  drain  with  rubber  cover. 


It  may  be  placed  to  either  side  of  the  median  line  in  case 
the  chief  discharge  is  expected  to  take  place  from  this 
position.  Hemorrhage  from  a  bleeding  surface  deep  in 
the  pelvis  may  often  be  controlled  by  the  direct  pressure 
of  the  end  of  the  gauze  drain  placed  over  it. 

The  drain  should  be  introduced  immediately  before  the 
abdominal  sutures  are  tied. 

Indications  for  Drainage. — Great  diversity  of  prac- 
tice exists  among  operators  as  to  the  use  of  drainage 
after  celiotomy.  A  few  use  it  in  the  majority  of  their 
cases;  others  use  it  but  little  if  at  all.  Much  depends 
upon  the  individual  methods  (?f  the  operator.  The 
operator  who  is  careless  in  his  asepsis   and   hemostasis 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  477 

should  use  drainage  oftener  than  he  who  is  careful  in 
these  particulars.  The  advice,  "  When  in  doubt  drain," 
is  very  good;  but  the  surgeon  should  strive  to  eliminate 
the  element  of  doubt  as  much  as  possible,  and  to  have  a 
definite  reason  for  all  his  procedures.  If  drainage  is  not 
necessary,  it  is  harmful.  It  necessitates  more  frequent 
dressings  and  disturbance  of  the  patient,  and  it  prevents 
perfect  closure  of  the  abdominal  incision. 

The  object  of  drainage  is  the  removal  from  the  perito- 
neum of  discharges  which  are,  or  which  may  become, 
septic  or  dangerous.  Such  discharges  are  blood,  pus, 
serum,  cyst-contents,  and  ascitic  fluid. 

Even  though  the  peritoneum  be  dry  and  all  bleeding 
be  arrested  when  the  operation  is  completed,  yet  it  must 
be  remembered  that  a  subsequent  free  serous  exudation 
will  take  place  if  the  peritoneum  has  been  exposed  or 
subjected  to  chemical  or  mechanical  irritation. 

Infection  may  take  place  from  imperfect  asepsis  at  the 
time  of  operation;  or  it  may  he  caused  by  the  escape  into 
the  peritoneum  of  septic  material  which  existed  in  the 
abdomen  before  the  operation;  or  it  may  occur  subse- 
quently, from  the  passage  of  septic  organisms  from  the 
interior  of  the  intestine  through  the  intestinal  wall. 

The  absorbing  power  of  the  healthy  peritoneum  is  so 
great  that  a  large  amount  of  fluid  (even  though  not  abso- 
lutely sterile)  may  be  taken  up  by  it.  Injury  of  the  peri- 
toneum from  exposure  or  other  irritation  not  only  in- 
creases the  amount  of  fluid  to  be  absorbed,  but  it 
diminishes  the  power  of  absorption;  and  injury  of  the 
intestinal  peritoneum  or  of  the  wall  of  the  intestine  favors 
the  passage  of  septic  organisms  through  it. 

The  operator  should  bear  these  facts  in  mind  when  he 
considers  the  subject  of  drainage, 

A  certain  amount  of  absorption  of  blood  or  other  sterile 
fluid  may  be  trusted  to  the  peritoneum. 

It  is  sometimes  impossible  to  arrest  all  venous  oozing 
from  raw  surfaces,  and  the  blood  must  be  left  for  absorp- 
tion by  the  peritoneum,  or  must  be  carried  off  by  drain- 


478      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

age  with  the  glass  tube  or  with  gauze.  Drainage  enables 
the  operator  to  watch  the  amount  of  hemorrhage  after 
operations,  so  that  if  excessive  he  may  employ  measures 
to  check  it.  Drainage  also  acts  as  a  hemostatic.  The 
direct  pressure  of  the  gauze  upon  the  bleeding  area 
checks  the  hemorrhage,  and  the  continual  removal  of 
blood,  the  promotion  of  dryness,  and  the  contact  of  air 
through  the  glass  tube  have  a  decided  hemostatic  effect. 

Drainage,  therefore,  is  sometimes  used  not  only  to  re- 
move blood,  but  to  aid  in  arresting  hemorrhage.  As  the 
operator  becomes  more  experienced  he  practises  more  per- 
fect hemostasis,  and  learns  to  obliterate  by  buried  suture, 
to  fold  in,  or  to  cover  with  peritoneum  raw  bleeding  sur- 
faces, so  that  drainage  as  a  means  of  hemostasis  is  less 
often  required.  If  the  operator  fears  that  the  peritoneum 
has  become  infected  from  imperfect  asepsis  at  the  opera- 
tion, or  from  the  escape  into  it  of  some  septic  material 
like  pus,  he  should  employ  drainage,  especially  if  he 
expects  much  subsequent  serous  or  bloody  discharge  to 
take  place. 

If  the  intestinal  wall  has  been  extensively  injured,  as 
we  sometimes  find  after  an  adherent  intestine  has  been 
liberated,  drainage  should  be  employed;  for  septic  organ- 
isms most  readily  pass  through  such  an  injured  wall,  and 
the  damage  may  be  so  great  that  necrosis  may  take  place, 
with  the  escape  of  intestinal  contents.  It  must  be  re- 
membered that  all  purulent  accumulations  in  the  abdo- 
men and  pelvis  are  not  septic.  Such  accumulations 
were  septic  in  the  beginning,  but  in  the  majority  of 
chronic  cases  the  septic  organisms  have  died  and  dis- 
appeared, and  the  pus  is  perfectly  sterile  and  harmless  to 
the  peritoneum.  Consequently,  if  an  ovarian  or  a  tubal 
abscess  ruptures  during  removal,  and  the  contents  escape 
into  the  peritoneum,  drainage  is  not  necessarily  required. 
For  a  period  of  three  years  the  writer  had  in  such 
cases  immediate  bacteriological  examination  of  the  pus 
made,  and  determined  drainage  from  the  result  of 
such  examination.     In  the  majority  of  cases  the  pus  was 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  479 

sterile  and  drainage  was  not  employed.  It  has  been 
found,  as  would  be  expected,  that  the  pus  is  most  often 
septic  in  the  cases  of  recent  suppuration  and  in  the 
chronic  cases  during  an  acute  attack.  Experience  also 
teaches  that  suppurating  dermoids  are  very  likely  to  be 
septic. 

It  will  be  seen  from  these  considerations  that  in  deter- 
mining the  question  of  drainage  much  must  be  left  to  the 
judgment  and  the  experience  of  the  operator. 

If  an  aseptic  operation  has  been  performed,  and  there 
is  no  intestinal  lesion  and  hemostasis  is  perfect,  drainage 
is  not  required.  This  condition  of  things  is,  of  course, 
most  often  attained  by  the  experienced  operator.  If  the 
operator  fears  septic  infection  for  any  reason,  or  fears  that 
the  hemostasis  is  not  good,  he  should  employ  drainage. 
At  the  present  day  the  decided  majority  of  the  best  opera- 
tors use  abdominal  drainage  very  little,  if  at  all. 

When  general  peritoneal  sepsis  exists  before  the  abdo- 
men is  opened,  drainage  is  always  indicated. 

Vaginal  Drainage. — Drainage  of  the  peritoneum 
through  .the  vagina  is  usually  accomplished  by  making 
an  opening  through  Douglas's  pouch  into  the  posterior 
.  vaginal  fornix.  A  rubber  drainage-tube  or  a  gauze  drain 
may  then  be  inserted.  The  vagina  and  vulva  should, 
of  course,  have  been  thoroughly  sterilized.  The  vagina 
should  be  lightly  packed  with  gauze,  and  the  vulva  should 
be  protected  by  a  gauze  and  cotton  dressing.  As  has 
been  said,  the  chief  objection  to  vaginal  drainage  of  the 
peritoneum  is  the  difficulty  of  sterilizing  and  maintaining 
sterile  the  vagina  and  the  vulva. 

The  Incision  of  the  Abdominal  "Wall. — The  vari- 
ous abdominal  operations  of  gynecology  are  performed 
through  an  incision  in  the  median  line.  The  position  of 
the  incision  depends  upon  the  condition  to  be  treated. 
The  incision  for  performing  ventro-suspension  of  the 
uterus  is  made  near  to  the  symphysis  pubis.  The  incis- 
ion for  the  removal  of  a  large  cyst  is  made  at  a  higher 
point.     As  a  rule,  the  incision,  about  2  or  2^2  inches  in 


48o     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

length,  should  be  made  about  midway  between  the  um- 
bilicus and  the  pubis,  and  should  be  extended  upward  or 
downward  as  necessary.  The  incision  should  be  as  small 
as  the  operator  can  conveniently  work  through.  He 
should  not  hesitate  to  enlarge  the  incision  to  facilitate 
any  manipulations.  The  length  will  depend  a  good  deal 
upon  the  thickness  of  the  abdominal  walls. 

The  structures  that  are  incised  are  the  skin,  the  sub- 
cutaneous fat,  the  parietal  fascia,  the  linea  alba  or  the 
edge  of  the  rectus  muscle,  the  subperitoneal  fat,  and  the 
peritoneum. 

If  the  incision  is  made  exactly  in  the  median  line,  the 
linea  alba  will  be  divided  and  the  sheath  of  the  rectus 
will  not  be  opened.  This  is  most  usual  in  multiparous 
women  with  lax  abdominal  walls  and  widely  separated 
recti  muscles,  and  in  cases  in  which  the  abdomen  is  dis- 
tended by  a  tumor.  If  the  sheath  of  the  rectus  is  opened, 
the  muscle  will  be  exposed,  and  the  linea  alba  should 
be  sought  on  the  side  upon  which  the  fascia  fails  to 
retract. 

If  the  linea  alba  cannot  readily  be  found,  the  incision 
should  be  carried  directly  through  the  muscle.  Some 
operators  consider  it  an  advantage,  in  obtaining  subse- 
quent firm  union,  to  expose  the  muscle  in  this  way. 
When  the  subperitoneal  fat  is  reached,  it  should  be  torn 
and  pushed  aside  with  the  blunt  closed  forceps  or  with  the 
fingers. 

The  peritoneum  should  be  caught  with  forceps  and 
drawn  forward.  The  assistant  should  catch  the  perito- 
neum with  a  second  pair  of  forceps  at  a  point  about  ^  or 
^  inch  to  the  side  of  the  first  pair,  and  the  small  fold 
of  peritoneum  thus  produced  should  be  incised  with  the 
knife.  As  soon  as  the  smallest  opening  is  made  in  the 
peritoneum  the  air  rushes  in  and  the  intestines  and  omen- 
tum fall  back.  The  opening  is  then  enlarged  with  the 
knife  or  scissors. 

The  greatest  care  must  be  exercised  in  those  cases  in 
which  the  omentum  or  the  intestines  are  adherent  to  the 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  481 

anterior  abdominal  wall.  The  experienced  operator  usu- 
ally observes  indications  of  such  a  condition  as  soon  as 
he  has  passed  through  the  linea  alba.  The  tissues  are 
more  rigid  and  unyielding  than  normal,  and  the  perito- 
neum cannot  be  readily  picked  up  with  the  forceps.  In 
such  cases  the  operator  should  proceed  very  slowly,  and 
if  necessary  should  enlarge  the  outer  incision  and  enter 
the  peritoneum  at  a  point  above  or  below  the  area  of 
adhesion. 

Bxploration  of  the  Abdomen. — Having  opened  the 
peritoneum,  the  operator  should  insert  two  fingers  (the 
middle  and  the  index  finger  of  the  left  hand)  and  should 
carefully  examine  the  condition  to  be  treated. 

If  necessary,  he  should  retract  the  edges  of  the  incision, 
and  should  place  the  patient  in  the  Trendelenburg  posi- 
tion, in  order  to  make  an  ocular  examination. 

It  is  always  advisable  to  make  a  preliminary  investiga- 
tion of  this  kind  before  proceeding  with  the  operation. 
In  this  way  the  diagnosis  will  be  corrected  and  complica- 
tions which  must  be  treated  will  be  determined.  It  may 
be  found  that  what  was  thought  to  be  a  cyst  is  in  reality 
a  uterine  fibroid  or  perhaps  a  normal  pregnancy;  or  the 
surgeon  may  discover  a  hopeless  condition,  such  as  ex- 
tensive cancer  or  peritoneal  papilloma,  for  which  further 
operation  will  be  useless. 

Protection  of  the  Intestines  and  Omentum. — Dur- 
ing all  manipulations  within  the  abdomen  the  perito- 
neum, intestines,  and  omentum  should  be  handled  most 
gently.  Injury  of  the  peritoneum  increases  the  danger 
of  shock,  sepsis,  and  intestinal  adhesions.  The  intes- 
tines should  never  be  allowed  to  protrude  through  the 
abdominal  incision  unless  it  is  necessary  for  the  perform- 
ance of  the  operation.  Such  a  necessity  rarely,  if  ever, 
arises  in  gynecological  operations.  All  the  intestines 
may  be  removed  from  the  field  of  operation — the  pelvis — 
by  placing  the  woman  in  the  Trendelenburg  position. 
Protrusion  of  intestines  through  the  abdominal  incision 
should  be  prevented  by  using  large  gauze  pads  or  sponges. 

31 


482      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

It  is  advisable  always  to  surround  the  field  of  operation 
by  a  wall  of  gauze  pads.  They  protect  the  intestines 
and  prevent  the  escape  of  fluids  into  the  upper  perito- 
neum. This  precaution  is  especially  desirable  when  the 
Trendelenburg  position  is  used,  to  prevent  fluids  from 
the  pelvis  escaping  into  the  upper  abdomen.  The  pads 
should  be  introduced  after  being  wrung  out  of  warm 
water,  and  should  be  replaced  by  fresh  Warm  pads  as  soon 
as  they  become  saturated  with  fluid.  If  they  become 
soiled  by  pus  or  other  septic  fluid,  it  is  safest  to  discard 
them  for  the  remainder  of  the  operation. 

Toilet  of  the  Peritoneum. — The  field  of  operation, 
and,  if  necessary,  the  general  peritoneum,  should  always 
be  cleaned  and  dried  before  the  abdominal  incision  is 
closed.  This  is  done  by  sponging  and  by  irrigation  with 
warm  sterile  water  or  with  normal  salt-solution.  The 
sponging  should  be  performed  with  great  gentleness,  to 
avoid  peritoneal  irritation.  There  are  several  regions 
in  which  fluids  and  blood-clots  are  most  likely  to  collect, 
and  which  therefore  demand  especial  inspection. 

The  chief  of  these  regions  is  the  hollow  of  the  sacrum, 
or  Douglas's  pouch.  Fluids  also  collect  on  the  anterior 
surface  of  the  broad  ligaments  and  in  the  renal  hollows. 

If  but  little  fluid  has  escaped  into  the  abdomen,  and 
the  field  of  operation  has  been  confined  to  the  pelvis,  we 
need  look  for  accumulations  of  fluid  and  blood  only  in 
Douglas's  pouch  and  in  front  of  the  broad  ligaments. 
If  the  upper  portion  of  the  abdomen  has  been  invaded, 
it  is  advisable  to  inspect  the  renal  hollows. 

Blood-clot  and  fluid  may  be  readily  removed  by  the 
sponge  held  in  the  fingers  or  in  forceps. 

Irrigation  of  the  peritoneum  is  not  often  required.  It 
is  not  necessary  to  flood  the  peritoneum  with  water  in 
order  to  wash  out  blood-clot,  which  may  be  removed  with 
more  accuracy  by  sponging.  There  is  always  danger, 
in  general  irrigation  of  the  peritoneum,  of  spreading  in- 
fection. 

Local  washing  of  the  pelvis  is  sometimes  advisable  if 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  483 

the  operator  fears  that  the  field  of  operation  has  been  in- 
fected by  the  escape  of  septic  material.  Such  a  condi- 
tion may  exist  in  operations  for  tubal  or  ovarian  abscess. 
The  upper  peritoneum  should  be  first  shut  off  from  the 
pelvic  cavity  with  a  wall  of  gauze  sponges.  This  may 
be  readily  done  while  the  patient  is  in  the  Trendelenburg 
position.  She  should  then  be  placed  in  the  horizontal 
position,  while  the  operator,  with  the  left  hand  pressed 
against  the  wall  of  pads,  prevents  the  intestines  entering 
the  pelvis.  The  abdominal  incision  should  be  held  open 
with  retractors,  and  the  sterile  irrigating  fluid  should  be 
poured  in  from  a  flask  or  a  pitcher.  The  temperature 
of  the  fluid  should  be  ioo°-ii5°  F.  The  fluid  may  be 
removed  by  sponging,  and  washing  may  be  repeated  as 
often  as  necessary. 

In  septic  cases  the  writer  has  frequently  performed  such 
local  washing  with  a  bichloride  solution  (i  :  2000  or  i  : 
4000),  followed  by  irrigation  with  plain  water. 

If  the  patient  is  horizontal  and  the  gauze  pads  be 
properly  placed,  there  is  no  danger  of  any  of  the  fluid 
entering  the  upper  peritoneal  cavity. 

Closing  the  Abdominal  Incision. — A  variety  of 
methods  have  been  introduced  for  closing  the  abdominal 
incision.  The  simplest  method,  that  is  applicable  to  all 
cases,  is  the  interrupted  mass-suture,  or  the  "  through- 
and-through "  suture.  This  suture  passes  through  all 
the  structures  of  the  abdominal  wall  (Fig.  205).     Some 


Fig.  205 — The  mass-suture  for  closing  the  abdominal  incision:   S,  skin;  F, 
fascia;   i)/,  muscle  ;   Z',  peritoneum. 

operators  advi.se  passing  the  suture  to,  but  not  through, 
the  peritoneum.  The  writer  includes  the  edge  of  the 
peritoneum  in  the  suture.    These  sutures  should  be  placed 


484      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 


two  or  three  to  the  inch,  according  to  the  thickness  of 
the  abdominal  wall. 

Care  should  be  taken  to  include  all  the  structures  in 
the  embrace  of  the  suture.  A  carelessly  applied  suture 
sometimes  fails  to  include  the  retracted  fascia  and  muscle. 
The  needle  should  first  be  directed  outward  and  then  in- 
ward as  it  passes  through  the  abdominal  wall.  It  should 
not  pass  directly  through,  parallel  to  the  sagittal  plane 
of  the  incision.  Thus  when  the  suture  is  tied  it  forms 
approximately  a  circle,  and  the  structures  included  in 
it  are  brought  into  a  plane  of  apposition. 

A  long  straight  needle  with  a  spear-point  is  conveni- 
ent for  introducing  the  mass-suture.     A  gauze  sponge 

should  be  placed  beneath  the 
incision  as  the  sutures  are 
introduced,  to  prevent  injury 
of  the  intestines  and  the  escape 
of  blood  into  the  peritoneum. 
When  the  pad  is  removed,  the 
omentum,  if  readily  found, 
should  be  drawn  down  behind 
the  incision.  Before  each 
suture  is  secured  the  sides  of 
the  incision  should  be  drawn 
forward  by  traction  on  the 
ends  of  the  suture,  to  ensure 
accurate  apposition  upon  the 
posterior  or  peritoneal  aspect. 
If  this  precaution  is  not  taken, 
in  a  thick  or  rigid  abdominal 
wall  the  cutaneous  aspect  of 
the  incision  may  be  brought 
into  accurate  apposition,  while 
a  gap  will  exist  between  the 
Such  imperfect  apposition  is 
a  frequent  cause  of  ventral  hernia.  The  mass-sutures 
should  not  be  removed  for  two  weeks.  The  early  re- 
moval of  sterile  sutures  is  of  no  advantage  whatever,  and 


Fig.  206 — The  subcuticular  or 
intra-cutaneous  suture.  The  fas- 
cia has  been  united  by  an  inter- 
rupted suture. 

more  posterior  structures. 


TECHNIQUE  OF  GYNECOLOGICAL  OPERATIONS.  485 

may  cause  ventral  hernia.  The  writer  often  leaves  them 
in  for  three  weeks. 

After  the  sutures  are  removed  the  incision  should  be 
strapped  with  adhesive  plaster. 

The  application  of  a  buried  suture  of  catgut  or  of 
silver  wire,  passed  through  the  muscle  and  fascia,  is  a 
useful  addition  to  the  mass-suture  and  an  additional  pre- 
ventive of  hernia. 

Various  methods  of  uniting  the  tissues  by  sutures  in 
separate  layers  are  used.  A  very  good  method  is  to  close 
the  peritoneum  by  a  continuous  suture  of  fine  silk,  then 
to  unite  the  muscle  and  fascia  by  a  continuous  suture  of 
catgut,  and  finally  to  close  the  cutaneous  edge  with  an 
interrupted  or  a  continuous  suture  of  silkworm  gut  or 
silk.  The  subcuticular  or  the  intra-cutaneous  suture 
(Fig.   206)  is  very  convenient  for  this  purpose. 

If  the  abdominal  wall  be  fat,  it  is  advisable  to  intro- 
duce a  second  catgut  suture  through  the  subcutaneous  fat. 
When  the  structures  are  united  in  layers,  a  hematoma 
sometimes  forms  between  two  planes  of  suture,  and,  if 
not  absorbed,  the  anterior  portion  of  the  wound  may 
break  down.  This  accident,  which  is  caused  by  hem- 
orrhage after  the  sutures  are  secured,  may  be  prevented 
by  employing,  in  addition  to  the  usual  dressing,  a  com- 
press of  gauze  placed  over  the  incision. 


CHAPTER  XLI. 
TREATMENT    AFTER    CELIOTOMY. 

The  after-treatment  of  celiotomy  is  usually  very  simple. 
A  special  nurse  is  required  for  the  first  three  days.  The 
patient  should  lie  upon  her  back  for  the  first  two  or  three 
days;  after  this  she  may  be  moved  partly  upon  either 
side,  and  a  pillow  may  be  placed  behind  her  for  support. 

The  head  may  be  supported  by  one  or  two  pillows. 
Much  comfort  is  experienced  by  raising  the  knees  over 
pillows.  The  patient  often  complains  bitterly  of  back- 
ache, which  may  be  relieved  by  slipping  a  folded  sheet  or 
towel  under  the  small  of  the  back. 

Thirst  is  always  present  after  celiotomy,  and  is  usually 
the  symptom  of  which  the  patient  complains  the  most. 
There  is  much  diversity  of  practice  in  regard  to  the  ad- 
ministration of  water  after  celiotomy.  The  writer  allows 
no  water  during  the  first  twenty-four  hours.  During  this 
time  the  lips  and  mouth  are  frequently  moistened  with 
a  cloth  wet  in  cold  water  or  wrapped  about  a  piece  of  ice. 
At  the  end  of  twenty-four  hours  small  quantities  of  hot 
water  or  cold  soda-water  (i  dram)  are  given  every  fifteen 
minutes  or  half  hour,  and  gradually  increased  as  it  is 
found  to  be  retained  by  the  stomach.  Hot  water  relieves 
thirst  as  well,  and  is  not  so  likely  to  cause  vomiting,  as 
cold  water. 

The  chief  objection  to  the  early  administration  of  water 
after  celiotomy  is  that  it  may  cause  vomiting.  Some 
operators  avoid  this  by  administering  the  water  by  the 
rectum. 

Another  reason,  more  or  less  theoretical,  for  withhold- 
ing water  is  that  the  absorbing  power  of  the  peritoneum 

486 


TREA  TMENT  OF  CELIO  TOMY.  487 

is  greatest  when  the  tissues  of  the  body  contain  a  deficient 
amount  of  water. 

Pain  after  celiotomy  seems  to  bear  no  relation  whatever 
to  the  amount  of  traumatism  that  has  been  inflicted. 
More  discomfort  may  be  experienced  after  ventro-suspen- 
sion  of  the  uterus  than  after  a  hysterectomy.  In  opera- 
tions upon  the  generative  organs  the  chief  seat  of  pain  is 
in  the  region  of  the  sacrum.  Pain  is  also  felt  in  the  ova- 
rian region  and  in  the  abdominal  incision.  The  pain 
begins  to  abate  after  the  first  fifteen  or  twenty  hours. 
Opium  should  not  be  administered  unless  it  is  absolutely 
necessary  to  allay  nervous  excitement  in  a  cowardly  wom- 
an. In  such  a  case  a  small  dose  (gr.  \)  of  morphine  may 
be  administered  hypodermically. 

The  writer  rarely  finds  it  necessary  to  administer  an 
anodyne.  Most  patients  are  able  to  endure  the  pain  if 
they  are  properly  encouraged  by  the  physician  and  the 
nurse. 

There  are  several  objections  to  the  administration  of 
opium.  It  increases  the  thirst  and  it  diminishes  the 
functional  activity  of  the  gastro-intestinal  tract.  It  re- 
tards the  passage  of  flatus  by  the  rectum  and  causes  tym- 
panites, and  it  increases  the  difficulty  of  moving  the 
bowels.  It  obscures  and  delays  the  recognition  of  symp- 
toms that  may  demand  immediate  treatment.  The  pa- 
tient who  has  had  no  opium  is  more  comfortable  at  the 
end  of  three  or  four  days  after  celiotomy  than  one  to 
whom  it  has  been  given. 

The  patient  should  be  encouraged  to  pass  water  volun- 
tarily. The  application  of  hot  moist  cloths  to  the  ex- 
ternal genitals  sometimes  facilitates  urination.  In  many 
cases  the  use  of  the  catheter  is  never  necessary.  If  the 
urine  is  not  voided  about  every  eight  hours,  it  should  be 
drawn  with  the  catheter.  Catheterization  should  be  done 
with  strict  attention  to  asepsis.  The  former  frequency 
of  cystitis  from  the  improper  use  of  the  catheter  has 
already  been  referred  to.  Catheterization  should  never 
be  performed  under  any  circumstances  by  the  aid  of  the 


488     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

tactile  sense  alone.  The  nurse  should  always  see  what  she 
is  doing.  The  catheter — metal,  glass,  or  preferably  soft 
rubber — should  be  sterilized  by  boiling,  and  should  be 
preserved  in  a   i  :  20  solution  of  carbolic  acid. 

The  catheter  may  be  lubricated  with  sterilized  oil  or 
glycerin.  The  labia  should  be  separated,  and  the  vesti- 
bule and  the  external  meatus  should  be  wiped  off  with  a 
solution  of  bichloride  of  mercury  (i  :  2000). 

After  the  catheter  has  been  used  once  it  should  be 
thoroughly  cleansed,  inside  and  out,  and  sterilized  by 
boiling  before  being  replaced  in  the  carbolic  solution. 

The  secretion  of  urine  is  always  diminished  for  a  few 
days  after  celiotomy,  probably  on  account  of  the  re- 
stricted ingestion  of  fluids.  The  writer  has  found  the 
average  secretion  in  iii  cases  of  celiotomy  to  be,  during 
the  first  twenty-four  hours,  13.4  ounces;  during  the 
second  twenty-four  hours,  14.6  ounces;  during  the  third 
twenty-four  hours,  19.6  ounces. 

Food  is  usually  first  administered  at  the  end  of  forty- 
eight  hours.  If  the  patient  be  feeble,  nutriment  may  be 
given  by  the  mouth  or  the  rectum  before  this  time.  The 
patient  may  have  any  easily  digested  food  that  she  wishes, 
such  as  buttermilk,  soup,  beef-tea,  milk  or  milk  and 
lime-water,  soft-boiled  ^^^.^  etc.  The  food  should  be 
given  frequently  in  small  quantities.  Buttermilk  is  one 
of  the  best  foods  with  which  to  begin.  It  gratifies  thirst 
and  is  more  readily  digested  than  milk.  Half  an  ounce 
to  an  ounce  may  be  given  every  hour  until  the  retentive 
power  of  the  stomach  is  determined. 

The  bowels  should  be  moved  at  the  end  of  forty-eight 
or  seventy-two  hours.  If  the  patient  is  uncomfortable 
and  is  unable  to  pass  flatus  freely,  or  if  there  is  any  ab- 
dominal distention,  the  purgative  should  be  administered 
at  the  earlier  time  (forty-eight  hours).  If  she  is  comfort- 
able and  passes  flatus  easily,  she  may  wait  for  three  days. 
Purgation  is  most  readily  produced  with  Rochelle  salts, 
given,  in  doses  of  ^  dram  in  about  3  or  4  ounces  of 
water  or  soda-water,  every  hour.     After  the  patient  has 


TREA  TMENT  OF  CELIO  TOMY.  489 

taken  five  or  six  doses  she  usually  feels  the  inclination  to 
have  a  movement.  If  she  is  unable  to  accomplish  this, 
she  may  be  assisted  with  a  rectal  injection  of  i  pint  of 
soap  and  water  and  2  drams  of  turpentine.  The  bowels 
should  be  moved  at  least  once  in  every  forty-eight  hours 
during  the  remainder  of  the  convalescence. 

Sometimes  the  bowels  are  more  difficult  to  move,  and 
it  is  necessary  to  repeat  the  rectal  injection  at  intervals 
of  two  or  three  hours  until  a  good  movement  is  produced. 
If  the  Rochelle  salts  are  not  retained  or  if  they  fail  to 
act,  I  grain  of  calomel  may  be  administered  every  hour 
for  five  or  six  hours. 

If  the  patient  does  well,  vomiting  does  not  often  occur 
after  the  first  twenty-four  hours,  when  the  effects  of  the 
ether  have  passed  off".  When  vomiting  occurs  later  than 
this,  it  is  usually  accompanied  by  abdominal  distention 
and  general  abdominal  pain.  It  is  then  an  alarming 
symptom,  and  may  indicate  the  onset  of  intestinal  par- 
alysis and  general  peritonitis. 

This  group  of  symptoms  (vomiting,  general  abdominal 
pain,  and  distention)  demands  immediate  treatment.     A 
hot  mustard  plaster  or  a  turpentine  stupe  should  be  placed 
over  the  epigastrium,  and  an  enema  of  i  pint  of  water 
and  y^  ounce  of  turpentine  should  be  administered,  and 
should  be  repeated  every  three  or  four  hours  until  a 'fecal 
movement  occurs  and  flatus  is  freely  discharged.     At  the 
same  time   Rochelle   salts   should    be   administered,  or, 
if  there  is  persistent  vomiting,  i-grain  doses  of  calomel.' 
The  escape  of  flatus  may  be  assisted  by  inserting  a  rectal 
tube.     In  case  of  moderate  distention  or  of  intestinal 
pain  from  inability  to  pass  flatus,   the  insertion  in  the 
anus  of  the  ordinary  rectal  nozzle  of  the  syringe  will 
usually  give  relief     If  this  is  not  sufficient,   the  long 
rectal  tube  or   a  large  rubber  catheter  should  be  intro"^ 
duced.     It  should  be  well  greased  and  passed  slowly  into 
the  rectum  for  a  distance  of  10  or  12  inches. 

The  patient  is  sometimes  able  to  pass  flatus  when  upon 
her  side,  though  she  may  not  be  able  to  do  so  upon  her 


490     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

back.  Inability  to  pass  flatus  is  not  necessarily  a  sign  of 
peritonitis  or  intestinal  paralysis.  It  may  be  caused  by 
the  unaccustomed  position,  or  pain  or  nervousness  may 
prevent  the  woman  relaxing  the  sphincter  ani. 

If  the  vomiting  persists  and  becomes  bilious,  relief  is 
sometimes  obtained  by  thoroughly  washing  out  the 
stomach  through  the  stomach-tube. 

The  internal  administration  of  medicines — except  the 
purgatives  already  mentioned — is  of  little  use  in  vomit- 
ing of  this  character. 

The  pulse  after  celiotomy  usually  remains  below  lOO. 
It  often,  however,  reaches  115  or  120,  and  sometimes 
higher,  in  patients  who  have  a  favorable  convalescence. 
A  rapid  pulse  unaccompanied  by  unfavorable  abdominal 
symptoms  often  indicates  some  heart-trouble. 

A  pulse  of  over  120  accompanied  by  abdominal  disten- 
tion and  vomiting  should  always  excite  alarm. 

Strychnine  and  digitalis,  administered  hypodermically, 
are  the  most  useful  medicines  for  strengthening-  the  heart 
and  diminishing  the  rapidity  of  the  pulse.  They  should 
be  given  in  large  doses — -^-^  of  a  grain  of  strychnine  every 
three  or  four  hours,  and  10  minims  of  tincture  of  digitalis 
at  similar  intervals. 

Hypodermic  injections  of  strychnine  are  most  useful 
for  shock  after  celiotomy.  This  drug  may  be  exhibited 
until  the  physiological  action — twitching  or  jerking  of  the 
muscles — is  observed.  The  writer  has  administered  be- 
tween I  and  2  grains  during  the  first  twenty-four  hours 
after  celiotomy,  with  recovery. 

The  temperature  after  celiotomy  runs  no  regular  course. 
It  usually  remains  below  102°  F.  A  greater  elevation  of 
temperature  than  this  may  occur  during  a  favorable  con- 
valescence; and,  on  the  other  hand,  a  fatal  termination 
may  take  place  when  the  temperature  remains  lower. 
The  maximum  temperature  is  usually  observed  about 
the  second  or  third  day. 

The  temperature  often  rises  on  account  of  very  trivial 
causes.     It  may  go  up  one  or  two  degrees  if  the  patient 


TREATMENT  OF  CELIOTOMY. 


491 


should  become  constipated,  and  will  drop  as  soon  as  a 
free  fecal  movement  has  taken  place. 

The  comfort  of  the  patient  is  much  increased  by 
sponging  the  arms  and  legs  with  tepid  water:  The  nurse 
should  be  instructed  to  sponge  the  patient  in  this  way 
whenever  the  temperature  reaches  102°  F. 


< 

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TEMPERATURE 
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Fig.  207. — Composite  temperature-chart  of  a  series  of  150  successful  cases 
of  celiotomy :  average  temperatures,  pulses,  and  respirations  for  two  weeks  after 
operation. 

The  patient  should  maintain  the  recumbent  posture  for 
three  weeks  after  celiotomy.  She  may  then  sit  up  in 
bed  for  two  or  three  days,  and  if  then  sufficiently  strong, 
she  may  leave  the  bed. 

Too  great  haste  in  getting  up  may  result  in  ventral 
hernia.     The  incision  should  be  strapped  with  adhesive 


492      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

plaster  for  five  or  six  weeks  after  operation,  and  the  wom- 
an should  wear  some  simple  form  of  abdominal  binder  for 
the  following  six  months,  or  for  a  year  if  the  incision  be 
large.  She  should  be  warned  against  resuming  hard 
work,  involving  lifting  or  other  abdominal  strain,  for  sev- 
eral months  after  operation.  She  should  be  told  of  the 
possibility  of  ventral  hernia,  and  advised  to  return  im- 
mediately for  treatment  should  this  condition  appear. 

The  usual  causes  of  death  after  celiotomy  are  perito- 
nitis and  hemorrhage.  The  frequency  of  hemorrhage  as 
a  cause  of  death  is  often  overlooked.  The  writer  feels  con- 
fident that  many  deaths  which,  without  post-mortem  ex- 
amination, are  attributed  to  peritonitis,  are  really  caused 
by  hemorrhage.  Without  doubt,  peritonitis  and  hemor- 
rhage often  occur  together;  the  blood  that  escapes  into 
the  peritoneal  cavity  may  be  too  great  in  amount  for  ab- 
sorption, and  may  become  septic.  The  source  of  the 
hemorrhage  is  usually  a  vessel  of  the  pedicle  that  escapes 
from  the  embrace  of  an  imperfectly  applied  ligature. 
This  accident  should  not  happen  if  the  operator  is  careful 
to  see  that  hemostasis  is  perfect  before  the  abdomen  is 
closed.  Bloody  oozing  from  a  surface  of  adhesion  is  not 
sufficient  to  cause  death,  and  may  be  removed  by  drain- 
age; the  fatal  hemorrhage  comes  from  an  arterial  vessel 
that  has  slipped  from  its  ligature.  All  ligatured  vessels 
should  be  finally  inspected  immediately  before  the  abdo- 
men is  closed.  If  a  stump  is  not  perfectly  dry,  a  rein- 
forcing ligature  should  be  applied.  Care  in  this  particular 
will  save  much  subsequent  anxiety.  If  the  operator 
knows  that  his  ligatures  have  been  securely  applied,  he 
can  exclude  the  possibility  of  hemorrhage  in  case  alarm- 
ing symptoms  should  arise. 

If  the  symptoms  of  the  patient  after  celiotomy  indicate 
hemorrhage,  the  abdomen  must  be  reopened  and  the 
bleeding  vessels  secured. 

The  causes  of  peritonitis  after  celiotomy  have  already 
been  discussed. 

The  common  symptoms  are  rapid  pulse,  abdominal  dis- 


TREA  TMENT  OF  CELIO  TOMY.  ^g^ 

tention  and  pain  with  inability  to  pass  flatus  or  feces,  and 
vomiting,  which  may  finally  become  stercoraceous.  The 
temperature  is  usually  elevated,  though  it  may  remain 
normal  or  subnormal.  Auscultation  of  the  abdomen  re- 
veals total  absence  of  all  peristaltic  sounds.  If  these 
symptoms  are  not  arrested  by  the  use  of  purgatives,  tur- 
pentine enemata,  and  the  rectal  tube,  it  is  probable  that 
the  result  will  be  fatal.  Death  usually  occurs  on  the 
third  day. 

The  mortality  after  celiotomy  depends  upon  the  con- 
dition to  be  treated,  the  skill  of  the  operator,  and  the 
environment  of  the  operation.  Some  operations,  like 
ventro-suspension  of  the  uterus,  are  attended  by  no  mor- 
tality. The  average  mortality  after  celiotomy  for  large 
numbers  of  gynecological  cases  of  all  kinds,  in  the  hands 
of  experienced  operators  with  good  operative  surround- 
ings, is  about  5  per  cent. 


CHAPTER  XLII. 

THE  SPECIAL  TECHNIQUE  OF  OPERATIONS  UPON 
THE  UTERUS  AND  THE  UTERINE  APPENDAGES. 


A  THOROUGH  knowledge  of  the  anatomical  relations 
of  the  various  structures  in  the  pelvis  is  essential  for  the 
performance  of  the  various  operations  upon  the  uterus 
and  its  appendages. 

A  detailed  description  of  such  anatomical  relations  is 
out  of  place  here.  It  is  especially  important  to  study 
the  distribution  of  the  arterial  supply  and  the  relations 


Fig.  208. — Posterior  view  of  the  uterus,  the  tubes  and  ovaries,  and  the  broad 
ligaments:  I.P.L.,  infundibulo-pelvic  ligament;  C.^.,  ovarian  artery;  U.A., 
uterine  artery ;  U.,  ureter.  The  utero-sacral  ligaments  are  seen  on  each  side 
of  the  posterior  aspect  of  the  cervix. 

of  the  ureters.     Fig.  208  will  refresh  the  memory  upon 

these  points. 

The  ovarian  artery,  which  corresponds  to  the  spermatic 

in  the  male,  is  a  branch  of  the  abdominal  aorta.     It  runs 
494 


SPECIAL  TECHNIQUE  OF  OPERA  TIONS.        495 

tortuously  between  the  layers  of  the  upper  part  of  the 
broad  ligament,  from  the  pelvic  wall  to  the  upper  angle 
of  the  uterus.  Before  reaching  the  uterus  it  divides  into 
two  branches.  The  upper  branch  supplies  the  fundus 
uteri;  the  lower  branch  anastomoses  at  the  side  of  the 
uterus  with  the  uterine  artery. 

During  its  course  in  the  broad  ligament  the  ovarian 
artery  gives  off  branches  to  the  ampulla  and  the  isthmus 
of  the  Fallopian  tube,  to  the  ovary,  and  to  the  round 
ligament. 

The  uterine  artery  arises  from  the  anterior  division  of 


Fig.  209.— Anterior  view  of  the  uterus,  the  tubes  and  ovaries,  and  the  broad 
Ugaments.  The  upper  part  of  the  bladder,  the  anterior  wall  of  the  vagina,  and 
the  peritoneum  on  the  anterior  aspect  of  the  broad  ligaments  have  been  re- 
moved. U.,  ureter;  £7.^.,  uterine  artery;  O.A.  ovarian  artery;  i?.Z.,  round 
ligament. 

the  internal  iliac,  and  runs  downward  and  inward  toward 
the  cervix  uteri.  The  vessel  is  tortuous,  and  is  loosely 
supported  by  the  cellular  tissue  at  the  base  of  the  broad 
ligament.  The  lowest  point  which  it  reaches  is  on  a  level 
with  the  external  os  uteri,  and  at  this  point  it  crosses  the 
ureter. 


496     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

At  about  this  point  it  gives  off  the  circular  artery  of 
the  cervix,  which  anastomoses  with  its  fellow  of  the  op- 
posite side.  The  uterine  artery  then  passes  upward,  and 
reaches  the  uterus  near  the  level  of  the  internal  os.  It 
passes  along  the  side  of  the  uterus  in  a  very  tortuous 
manner,  and  anastomoses  with  the  ovarian  artery. 

The  vaginal  arteries  usually  arise  from  the  anterior 
division  of  the  internal  iliac  artery.  They  sometimes 
arise  from  the  uterine  or  middle  hemorrhoidal  artery. 

The  ureter  passes  behind  and  beneath  the  uterine 
artery.  The  uterine  artery  crosses  the  ureter  at  about  the 
level  of  the  external  os  uteri.  At  this  point  the  ureter  is 
f  of  an  inch  distant  from  the  cervix.  The  distance  be- 
tween the  ureter  and  the  artery  at  the  point  of  crossing 
is  about  f  of  an  inch.  It  is  important  to  remember  these 
relations  in  applying  a  ligature  to  the  uterine  artery. 

It  must  not  be  forgotten  that  the  anatomical  relations 
are  altered  by  any  displacement  of  the  uterus  from  its 
normal  position.  Such  displacement  occurs  in  disease  and 
when  the  uterus  is  dragged  upward  or  downward  during 
operation. 

In  conditions,  such  as  cancer,  which  are  accompanied 
by  hypertrophy  of  the  cervix,  the  distance  between  the 
ureter  and  the  cervix  is  much  diminished. 

Removal  of  the  Uterine  Appendages  (Salpingo- 
obphorectomy). — This  operation  is  performed  by  liga- 
turing the  ovarian  artery  in  its  course  through  the  in- 
fundibulo-pelvic  ligament  and  at  the  uterine  cornu,  and 
then  excising  the  Fallopian  tube  and  the  ovary. 

The  peritoneum  is  opened,  and  the  index  and  middle 
fingers  of  the  left  hand  are  introdiiced  into  the  abdomen. 
If  necessary,  the  omentum  is  swept  upward  out  of  the 
pelvis.  The  fundus  uteri  is  sought,  and  the  fingers,  with 
the  palmar  surface  directed  downward,  are  passed  over 
the  posterior  face  of  the  uterus,  and  then  outward  over 
the  posterior  aspect  of  the  broad  ligament.  The  ovary 
and  tube  are  palpated,  and  are  lifted  forward  upon  the 
palmar  aspect  of  the  two  fingers  or  between  the  fingers, 


SPECIAL  TECHNIQUE  OF  OPERA  TIONS.        497 

perhaps  with  the  subsequent  assistance  of  the  thumb, 
into  the  abdominal  incision.  The  infundibulo-pelvic 
ligament  is  exposed,  and  is  rendered  tense  by  the  pres- 
sure of  the  fingers  behind  it.  It  will  be  observed  that 
the  upper  edge  of  the  ligament  is  thick,  while  there  is  a 
thin,  sometimes  transparent,  area  below  the  free  edge. 
The  vessels  run  in  the  upper  edge  of  the  ligament,  and  a 
ligature  passed  through  the  thin  area  will  secure  them 
(Fig.  210). 


Fig.  210..— Salpingo-oophorectomy.  On  the  right  side  ligatures  have  been 
placed  about  the  ovarian  artery,  at  the  uterine  horn,  and  at  the  pelvic  wall.  On 
the  left  side  the  tube  and  ovary  have  been  excised  between  such  ligatures.  If 
bleeding  takes  place  from  the  broad  ligament,  the  anterior  and  posterior  peri- 
toneal aspects  may  be  united  by  suture. 

The  heavy  silk  carried  in  the  pedicle-needle  should  be 
used.  The  ligature  should  be  placed  sufficiently  near  the 
pelvic  wall  to  permit  complete  excision  of  the  tube  and 
ovary  without  cutting  too  close  to  the  ligature.  The 
broad  ligament  should  then  be  transfixed  by  a  second 
ligature  at  a  point  somewhat  to  the  inside  of  the  first. 
The  second  ligature  should  embrace  the  ovarian  liga- 
ment, the  isthmus  of  the  tube,  and  the  uterine  end  of 
the  ovarian  artery.  This  ligature  should  be  placed  close 
to  the  uterine  cornu,  in  order  to  permit  complete  ex- 
cision of  the  ovary. 

.32 


498     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  Fallopian  tube,  the  ovary,  and  the  mesosalpinx 
are  then  cut  away  with  the  scissors.  There  is  usually  no 
bleeding  whatever  from  the  unligatured  portion  of  the 
broad  ligament  between  the  two  ligatures.  The  stumps 
should  be  carefully  inspected,  and  any  bleeding  point  in 
the  intervening  portion  of  the  broad  ligament  should  be 
picked  up  and  secured  by  fine  ligature;  or  the  peritoneal 
edges  may  be  united  by  suture. 

It  seems  to  the  writer  that  this  method  of  operating  is 
in  accord  with  the  best  surgical  principles. 

The  vessels  are  secured  in  their  course  by  ligatures 
which  embrace  a  minimum  amount  of  surroundins^  tis- 
sue.  The  operation  usually  advised,  however,  is  per- 
formed with  the  Tait  knot  (Fig.  2ii)  or  the  link-ligature 
(Fig.  212). 


Pig.  211. — Tlie  Tait  knot.  FiG.  212. — The  link-ligature. 

The  ovary  and  the  tube  are  drawn  into  the  abdominal 
incision,  and  the  pedicle  formed  by  the  broad  ligament  is 
transfixed  with  the  pedicle-needle  carrying  a  double  liga- 
ture. 

The  loop  of  the  ligature  is  passed  over  the  tube  and 
ovary  and  the  Tait  knot  is  tied,  or  the  ligature  is  cut  and 
each  half  of  the  pedicle  is  separately  secured,  the  ligature 
being  crossed  or  linked  in  the  middle  of  the  stump,  to 
prevent  separation. 

The  operators  who  apply  the  ligature  in  this  way  do  so 
because  they  fear  hemorrhage  if  every  portion  of  the 
broad  ligament  is  not  secured. 

This  fear  is  unfounded.  The  objections  to  this  form 
of  ligature,  the  Tait  or  the  link-ligature,  may  be  given  by 
the  following  quotation  from  a  former  paper  by  the  writer.  ^ 

^  "  The  Ligature  in  Oophorectomy,"  read  before  the  Philadelphia  Academy 
of  Surgery,  February  3,  1896. 


SPECIAL  TECHNIQUE  OF  OPERATIONS.        499 

"The  objections  to  these  ligatures  are:  The  liability  to 
slip;  the  difficulty  or  impossibility  in  some  cases  of  re- 
moving all  the  ovary  and  tube;  the  fact  that  the  broad 
ligament  is  puckered  up  and  made  more  tense  than  nor- 
mal, and  may  for  this  reason  cause  subsequent  pain  and 
discomfort;  an  unnecessary  amount  of  tissue  is  strangu- 
lated. 

"  Most  operators  have  seen  cases,  either  in  their  own 
experience  or  in  the  experience  of  others,  in  which  the 
ligature  has  slipped  from  the  pedicle,  either  during  the 
operation  or  some  days  afterward.  I  think  that  this 
accident,  usually  unrecognized,  is  a  very  common  cause 
of  death  after  oophorectomy.  Tait  speaks  of  a  certain 
number  of  cases  in  his  own  experience  in  which  a  hema- 
toma occurred  in  the  broad  ligament  some  hours  or  days 
after  operation.  He  says,  '  I  cannot  form  any  exact  esti- 
mate of  how  many  cases  of  these  operative  hematoceles 
I  have  seen,  but  it  certainly  is  not  less  than  50,  and  is 
more  likely  to  be  70  or  80.' 

"  It  seems  probable  that  this  accident  is  due  to  the  re- 
traction or  slipping  of  the  artery  from  the  embrace  of  the 
ligature,  while  the  remaining  mass  of  tissue  which 
forms  the  pedicle  is  still  retained,  and  the  hemorrhage, 
therefore,  is  confined  to  the  broad  ligament.  I  have  seen 
this  accident  happen  before  the  abdomen  had  been  closed, 
and  have  sought  for  and  ligated  separately  the  retracted 
vessel. 

"Slipping  of  the  ligature  is  due  to  the  form  of  the 
mass  of  tissue  which  is  ligated.  The  broad  ligament  is 
drawn  up  into  a  more  or  less  conical  shape,  all  parts  con- 
verging toward  the  ligature,  and  the  ligature  is  really 
placed  at  the  apex  of  a  cone  from  which  it  may  readily 
slip;  and  the  elastic  artery,  tied  when  upon  the  stretch, 
tends  to  retract  and  escape  from  the  embrace  of  the  liga- 
ture. 

"The  second  objection  is  the  difficulty  or  impossibility 
of  removing  all  the  ovary  and  tube.  If  the  broad  liga- 
ment is  tense,  as  it  often  is  in  single  women,  or  if  it  is 


500     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

thickened  from  inflammatory  deposit,  it  is  sometimes  im- 
possible to  bring  the  tube  and  ovary  through  the  abdom- 
inal incision  and  to  obtain  a  pedicle  which  may  be  ligated 
so  that  we  may  with  safety  remove  all  of  the  ovary. 
And  it  is  in  just  such  cases  that  it  is  usually  most  desira- 
ble that  all  ovarian  tissue  should  be  removed. 

"The  third  objection — the  puckering  and  tension  of 
the  broad  ligament — may  be  of  less  importance  than 
those  just  considered.  However,  it  seems  probable  that 
some  of  the  pain  which  women  suffer  after  oophorectomy 
is  due  to  the  traction  and  counter-traction  exerted  by 
different  parts  of  the  broad  ligament  upon  a  sensitive 
cicatrix.  The  broad  ligament  is  pulled  up  from  different 
directions  and  converges  to  the  cicatrix,  which  becomes 
the  point  from  which  the  lines  of  traction  radiate. 

"It  was  thought  that  in  case  of  retroversion  this  ten- 
sion of  the  broad  ligament  would  maintain  the  uterus  in 
place,  the  ligaments  acting  as  guys.  This,  however,  is 
not  true.  Repeated  secondary  operations  have  shown 
that  the  uterus  has  fallen  back  again  to  extreme  retro- 
version, notwithstanding  such  methods  of  ligature  of  the 
broad  ligaments. 

"The  fourth  objection  is  one  which  appeals  to  our 
surgical  sense.  It  is  always  better  surgery  to  ligate 
the  vessel  alone  than  to  include  with  it  a  mass  of  sur- 
rounding tissue." 

If  the  isthmus  of  the  Fallopian  tube  is  diseased,  as  in 
some  cases  of  pyosalpinx,  so  that  it  is  necessary  to  exsect 
the  tube  from  the  uterine  cornu,  the  second  ligature  may 
be  passed  immediately  beneath  the  tube,  including  the 
ovarian  ligament  and  the  ovarian  artery,  but  not  includ- 
ing the  tube;  the  tube  may  then  be  cut  out  by  a  wedge- 
shaped  incision  in  the  horn  of  the  uterus.  In  such  cases, 
however,  if  the  tubal  disease  is  bilateral,  it  is  best  to  re- 
move the  uterus  as  well  as  the  appendages. 

It  is  not  necessary  to  place  both  ligatures  before  cut- 
ting awa}-^  the  ovary  and  tube.  The  first  ligature  may 
be  placed   about   the   proximal   portion    of    the    ovarian 


SPECIAL   TECHNIQUE  OF  OPERATIONS.        501 

artery,  and  then  the  infnndibulo-pelvic  ligament  may  be 
cut,  bleeding  from  the  distal  end  being  controlled  with 
forceps.  This  will  enable  the  operator  readily  to  bring 
the  ovary  and  tube  through  the  incision  and  to  ligate  the 
ovarian  artery  at  the  uterine  cornu. 

If  adhesions  exist,  they  should  be  broken  with  the 
fingers,  or  the  patient  should  be  placed  in  the  Trendelen- 
burg position  and  the  adhesions  should  be  divided  with 
scissors.  The  tube  and  ovary  are  sometimes  completely 
imbedded  in  adhesions,  and  it  is  necessary  to  shell  them 
out  by  careful  work  with  the  fingers.  The  adhesions 
may  be  so  dense  and  the  anatomical  relations  so  altered 
that  it  is  difficult  or  impossible  to  determine  what  is  ovary 
and  what  is  tube  until  the  mass  is  brought  into  the  abdom- 
inal incision.  In  these  cases  the  experienced  operator  may 
work  by  the  sense  of  touch  alone.  The  inexperienced 
operator  had  better  expose  the  parts  and  obtain  the  as- 
sistance of  visual  examination. 

The  fundus  uteri  can  usually  be  determined,  and  will 
form  a  valuable  landmark.  The  enucleation  is  most 
easily  performed  with  the  fingers.  The  index  and  middle 
fingers,  with  the  palmar  surfaces  turned  downward, 
should  be  passed  outward  from  the  posterior  aspect  of  the 
uterus,  and  should  seek  a  plane  along  which  the  struc- 
tures most  readily  separate.  As  a  rule,  adhesions  give 
way  more  easily  than  the  tissues  of  normal  structures. 
Adhesions  should  not  be  roughly  torn:  they  should  be 
pushed  away  from  the  posterior  aspect  of  the  ovary  and 
broad  ligament. 

The  adhesions  between  the  ovary  and  the  broad  liga- 
ment must  be  broken  by  pressure  with  the  fingers  before 
the  ovary  can  readily  be  brought  into  the  abdominal  in- 
cision. 

After  all  other  adhesions  have  been  relieved  it  is  often 
found  that  the  ovary  still  lies  low  in  the  pelvis,  glued  to 
the  posterior  aspect  of  the  broad  ligament.  It  should 
not  be  dragged,  in  this  condition,  into  the  incision,  or 
the  broad  ligament  may  be  badly  lacerated.     It  should 


502     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN, 

be  peeled  ofif  from  the  broad  ligament  and  rolled  up  to 
the  incision. 

After  the  structures  have  been  carefully  examined  and 
the  anatomical  relations  determined  the  ligatures  should 
be  placed  and  the  tube  and  ovary  cut  away.  The  bleed- 
ing from  the  pelvic  adhesions  is  usually  arrested  or  much 
diminished  as  soon  as  the  ovarian  artery  is  ligated.  It  is 
best,  therefore,  to  waste  no  time  in  attempts  to  arrest 
moderate  hemorrhage  until  the  appendages  have  been  re- 
moved. The  pelvis  should  then  be  inspected  and  any 
bleeding  points  secured.  Omental  adhesions  should  be 
ligated,  if  necessary,  as  they  are  divided. 

If  there  is  a  general  oozing  from  the  bed  of  adhesions 
that  cannot  be  controlled  by  ligature,  one  or  two  gauze 
pads  should  be  pressed  over  the  region  and  retained  there 
until  the  abdominal  sutures  have  been  placed.  If  the 
bleeding  continues  notwithstanding  such  sponge-pressure, 
it  may  be  necessary  to  employ  drainage.  The  bleeding 
may  always  be  controlled  by  the  pressure  of  the  end  of 
the  gauze  drain  placed  directly  over  the  raw  surface. 

If  the  operator  is  anxious  to  arrest  menstruation,  he  must 
be  certain  to  remove  all  ovarian  tissue  and  the  Fallopian 
tubes  at  the  uterine  cornua.  Sometimes,  after  an  adhe- 
rent ovary  has'  been  enucleated,  part  of  the  ovarian 
stroma  remains  glued  to  the  pelvic  wall,  the  posterior 
face  of  the  broad  ligament,  or  some  other  structure. 
These  portions  of  ovary  should  be  carefully  picked 
off  with  the  forceps.  If  the  operator  doubts  the  com- 
plete removal  of  all  ovarian  tissue,  he  should  make  a 
note  to  this  effect  in  the  history  of  the  case.  Were  this 
always  done,  the  existence  of  a  supernumerary  ovar}^ 
would  not  be  so  often  assumed. 

The  directions  that  have  been  given  here  appl}^  to  the 
removal  of  tubal  tumors  and  small  cystic  and  solid  tumors 
of  the  ovary.  When  the  ovary  is  removed  there  is  but 
little,  if  any,  advantage  in  leaving  tbe  corresponding 
Fallopian  tube  in  case  the  tube  on  the  opposite  side  is 
healthy. 


SPECIAL   TECHNIQUE  OF  OPERA  TIONS.        503 

If  the  patient  is  anxious  for  children,  the  operator 
should  remember  that  conception  is  possible  with  one 
tube  and  one  ovary,  though  they  be  on  opposite  sides. 
If  an  ovarian  tumor  is  removed  independently  of  the 
corresponding  Fallopian  tube,  the  pedicle  of  the  ovary 
should  be  transfixed  and  ligatured  in  two  or  more  masses. 

Removal  of  an  Ovarian  Cyst. —The  removal  of  a 
large  ovarian  cyst  may  be  facilitated  by  preliminary  tap- 
ping as  soon  as  the  peritoneum  is  opened,  and  withdrawal 
of  the  fluid  conteiits.  As  a  general  rule,  this  procedure 
is  advisable  if  the  cyst  is  too  large  to  be  removed  through 
a  3-  or  4-inch  incision.  If,  however,  the  operator  should 
suspect  the  contents  of  the  cyst  to  be  septic,  it  is  safest 
to  enlarge  the  incision  and  to  remove  the  tumor  intact, 
thus  avoiding  infection  of  the  peritoneum.  This  advice 
is  especially  applicable  to  dermoid  cysts.  The  contents 
of  such  cysts  are  very  often  septic.  They  are  thick,  and 
contain  a  large  amount  of  solid  material  which  passes 
with  difficulty  through  the  trocar.  The  walls  of  the  cyst 
are  friable  and  easily  torn,  so  that  the  puncture-wound 
of  the  trocar  becomes  enlarged  and  the  cyst-contents 
escape  around  it;  and,  finally,  the  contents  of  a  dermoid 
are  very  difficult  to  remove  from  the  peritoneum. 

The  dermoid  character  of  a  cyst  may  be  suspected  from 
the  dull  appearance  of  the  walls  and  the  putty-like  feel- 
ing upon  palpation.  They  are  usually  of  small  size,  and 
may  be  removed  bodily  through  an  incision  of  moderate 
extent. 

Every  tumor  should  be  carefully  examined  before  the 
trocar  is  plunged  into  it.  The  operator  should  make 
certain  by  palpation  that  the  tumor  is  cystic.  The  trocar 
has  been  thrust  into  the  pregnant  uterus,  and  frequently 
into  a  fibroid  tumor.  In  the  case  of  a  fibroid  profuse 
hemorrhage  may  occur  from  such  an  accident.  The 
hemorrhage  may  usually  be  controlled  by  forcing  a  small 
sponge  or  gauze  pack  into  the  puncture  wound.  Before 
tapping  the  cyst  the  operator  should  pass  his  hand  around 
it  and  determine  the  position  and  character  of  adhesions.. 


504     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Small  cysts  about  the  size  of  a  child's  head  may  be 
tapped  with  the  small  trocar.  The  larger  instrument  is 
used  in  cysts  of  greater  size. 

In  a  multilocular  cyst  the  largest  loculus  should  be 
tapped  first.  Sponges  should  be  placed  in  the  abdomen 
around  the  point  selected  for  puncture.  An  incision 
about  half  an  inch  in  length  should  be  made  through  the 
outer  coat  of  the  cyst,  and  the  trocar  should  then  be  in- 
troduced. As  the  fluid  escapes  through  the  trocar  and 
the  rubber  tube  into  a  vessel  at  the  side  of  the  table,  and 
as  the  cyst  becomes  flaccid,  the  wall  of  the  cyst  near  the 
trocar  should  be  seized  with  large  forceps.  As  the  tumor 
diminishes  in  size  it  should  be  dragged  through  the  ab- 
dominal incision.  This  procedure  should  not  be  done 
quickly  or  roughly,  or  adherent  intestines  may  be  torn, 
and  bleeding  from  omental  adhesions  may  escape  detec- 
tion. 

As  the  cyst  is  drawn  out  the  surface  should  be  exam- 
ined and  adhesions  should  be  separated,  and  ligatured,  if 
necessary,  as  they  appear.  Omental  adhesions  usually 
require  ligature.  The  bleeding  from  omental  vessels  is 
often  profuse  and  is  not  arrested  spontaneously.  An  ad- 
herent omentum  should  be  ligatured  with  medium-sized 
silk  in  small  sections,  not  in  one  mass,  before  it  is  cut 
away  from  the  tumor. 

The  intestine  is  sometimes  so  adherent  to  the  surface 
of  the  tumor  that  it  cannot  be  separated  without  serious 
danger  to  the  intestinal  wall.  In  such  a  case  it  is  best 
to  cut  out  the  adherent  portion  of  the  outer  wall  of  the 
tumor  and  leave  it  glued  to  the  intestine.  If  there  is 
bleeding  from  the  raw  surface,  it  may  be  checked  by 
folding  in  the  bleeding  area  with  silk  suture. 

While  the  operator  is  dealing  with  the  adhesions  the 
assistant  should  see  that  the  opening  in  the  cyst  is  kept 
in  a  dependent  position  and  that  cyst-contents  do  not 
escape  into  the  abdomen.  This  precaution  should  always 
be  taken,  though  it  is  especially  important  in  the  cases 
of  septic  and  papillomatous  cysts. 


SPECIAL  TECHNIQUE  OF  OPERA  TIONS.        505 

When  the  pedicle  of  the  cyst  is  exposed,  it  should  be 
ligatured  as  already  advised.  If  the  stump  of  the  pedicle 
is  very  broad,  it  may  be  folded  in  or  covered  with  peri- 
toneum to  prevent  intestinal  adhesions  to  it. 

The  other  ovary  should  always  be  examined  before 
closing  the  abdomen. 

Operation  for  the  Removal  of  Intraligamentous 
Cysts. — Intra-ligamentous  cysts  grow  between  the  folds 
of  the  broad  ligament.  Any  oophoritic  tumor  may  be 
intra-ligamentous,  though  the  condition  is  most  usually 
found  in  cysts  of  the  paroophoron  and  the  parovarium. 

The  intra-ligamentous  cyst  may  drag  out  the  broad 
ligament  so  that  a  pedicle  may  be  formed,  and  the  tumor 
ma}'  be  removed  by  the  methods  already  described. 

In  other  cases,  however,  the  cyst  is  strictly  sessile.  It 
lies  between  the  layers  of  the  broad  ligament,  deep  in  the 
pelvis,  or  perhaps  it  may  have  migrated  to  some  other 
part  of  the  abdomen  behind  the  peritoneum. 

The  removal  of  such  tumors  requires  accurate  ana- 
tomical knowledge  of  the  region  in  which  the  growth  is 
situated. 

It  is  necessary  to  incise  the  peritoneal  covering  of  the 
tumor  and  to  enucleate  it  from  its  bed.  The  peritoneum 
should  be  incised  in  the  position  in  which  there  are  few- 
est blood-vessels.  Thus,  if  the  tumor  has  migrated  be- 
tween the  layers  of  the  mesocolon,  the  incision  should  be 
made  through  the  outer  peritoneal  layer. 

Intra-ligamentous  cysts  often  have  no  pedicular  attach- 
ments whatever,  and  may  be  enucleated  without  the  ap- 
plication of  ligature.  In  other  cases  a  distinct  vascular 
pedicle  is  found  after  the  peritoneal  investment  has-been 
opened  and  its  adhesions  to  the  cyst-wall  have  been  sep- 
arated. 

The  relations  of  an  intra-ligamentous  cyst  should  be 
carefully  examined  before  the  surgeon  proceeds  with  the 
operation,  and  such  a  cyst  should  not  be  mistaken  for  an 
extra-ligamentous  cyst  that  has  become  adherent. 

If  the  tumor  is  situated  between  the  layers  of  the  broad 


5o6      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

ligament,  it  is  advisable,  as  a  preliminary  step,  to  ligate 
the  ovarian  artery  in  the  infundibulo-pelvic  ligament  and 
at  the  cornu  of  the  uterus.  This  may  usually  be  readily 
done;  much  subsequent  bleeding  will  be  prevented  by  it. 

The  peritoneum  is  then  incised  at  the  most  convenient 
point  over  the  surface  of  the  tumor,  and  the  surgeon, 
with  the  fingers,  knife-handle,  or  closed  blunt  scissors, 
proceeds  with  the  enucleation.  If  inflammatory  adhe- 
sions have  not  taken  place,  enucleation  is  usually  easy. 
Bleeding  vessels  should  be  secured  by  forceps  as  they  ap- 
pear, and  should  be  ligated,  if  necessary,  after  the  cyst  is 
removed. 

If  a  pedicle  or  fleshy  adhesion  is  met,  it  should  be 
ligated  before  division. 

During  the  enucleation  the  surgeon  should  follow  closely 
the  surface  of  the  tumor.  When  he  has  reached  a  point 
deep  in  the  pelvis  he  should  be  especially  careful  to  avoid 
injury  of  the  large  vessels  and  the  ureter.  If  the  cyst  is 
difficult  of  removal  in  this  region,  it  may  be  advisable  to 
cut  out  a  portion  of  the  cyst-wall  and  leave  it. 

Preliminary  tapping  of  intra-ligamentous  cysts  is  not 
often  necessary.  They  are  usually  of  moderate  size,  and 
enucleation  may  be  most  readily  performed  if  the  cyst  is 
tense. 

Sometimes  large  cysts  are  but  partly  intra-ligamentous: 
the  greater  portion  is  free,  while  the  base  is  included  be- 
tween the  layers  of  the  broad  ligament.  In  such  cases  it 
is  best  to  tap  the  cyst  and  then  to  enucleate  the  base  as 
already  described. 

In  other  cases  the  process  of  enucleation  may  be  facili- 
tated and  rendered  safe  by  incising  the  cyst-wall  and  in- 
troducing two  fingers  into  the  cavity  to  act  as  guides  in 
separating  the  cyst  from  structures  deep  in  the  pelvis. 

After  the  cyst  has  been  removed  and  bleeding  points 
have  been  secured  by  ligature,  the  raw  surface,  or  the  bed 
of  the  tumor,  may  be  obliterated  by  bringing  the  sides 
into  apposition  by  la^^ers  of  buried  fine  silk  sutures  and 
by  closing  with   suture   the  incision  in  the  peritoneum. 


SPECIAL   TECHNIQUE  OF  OPERA  TIONS.        507 

These  raw  surfaces  often  contract  very  much  by  the  fall- 
ing together  of  the  sides  after  the  tumor  has  been  re- 
moved. 

If  bleeding  from  the  bed  of  the  tumor  cannot  be  thor- 
oughly arrested,  it  is  unsafe  to  close  the  incision  in  the 
peritoneum,  for  a  hematoma  will  form  and  will  cause  sub- 
sequent trouble.  In  such  a  case  the  gauze  drain  should 
be  introduced  into  the  bed  of  the  tumor,  perhaps  after 
partial  closure  of  the  peritoneal  incision.  Or  if  the  bleed- 
ing be  very  profuse,  the  edges  of  the  incision  in  the 
broad  ligament  should  be  sutured  to  the  lower  angle  of 
the  abdominal  wound,  and  the  cavity  should  be  packed 
with  gauze. 

The  sutures  that  attach  the  broad  ligament  to  the  ab- 
dominal incision  may  be  passed  through  the  whole  thick- 
ness of  the  abdominal  wall,  or  through  only  the  fascia, 
muscle,  and  peritoneum.  The  ends  of  the  sutures  should 
be  left  long  to  facilitate  removal. 

In  the  removal  of  a  cyst  of  the  parovarium  by  enucle- 
ation, the  tube  and  ovary  should  not  be  sacrificed  unless 
they  are  diseased.  Small  cysts  of  the  parovarium  which 
develop  between  the  layers  of  the  mesosalpinx  may  very 
easily  be  removed  by  simple  incision  of  the  peritoneal 
capsule  and  enucleation  of  the  cyst,  without  injury  to 
the  tube  and  ovary. 

Marsupialization  of  the  Cyst.— In  rare  cases  a  cyst 
is  found  to  be  so  firmly  and  generally  adherent  to  sur- 
rounding structures  that  its  removal  is  impossible.  It  is 
then  necessary  to  practise  marsupialization. 

The  cyst  should  be  evacuated  with  the  trocar,  which  is 
introduced  at  a  point  which  can  be  readily  brought  to  the 
abdominal  incision.  Vegetations,  etc.  should  be  removed 
from  the  interior  of  the  cyst  with  the  fingers.  The 
opening  in  the  cyst  should  then  be  attached  to  the  lower 
angle  of  the  abdominal  incision  by  interrupted  sutures 
of  strong  silk  that  pass  through  the  whole  thickness  of 
the  abdominal  wall  and  of  the  cyst-wall.  The  sutures 
should  be  placed  close  together,  and  the  ends  should  be 


5o8      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

left  long  to  facilitate  removal.  The  upper  portion  of  the 
abdominal  incision  should  be  closed  with  interrupted 
sutures. 

A  large  double  drainage-tube  of  rubber  should  be  intro- 
duced into  the  cyst,  and  strips  of  gauze  should  be  packed 
around  the  tube. 

The  subsequent  treatment  consists  of  frequent  washing 
of  the  interior  of  the  cyst.  The  sutures  in  the  cyst-wall' 
should  be  removed  at  the  end  of  two  weeks. 

Though  marsupialization  frequently  results  in  cure,  yet 
it  should  never  be  practised  unless  it  is  absolutely  neces- 
sary. It  exposes  the  patient  to  the  dangers  of  prolonged 
suppuration  and  persistent  fistula.  Malignant  degenera- 
tion has  occurred  in  the  wound.  Papilloma  may  extend  to 
the  peritoneum.  The  procedure  is  of  but  little  use  in  the 
case  of  multilocular  tumors,  as  all  the  loculi  cannot  be 
evacuated. 


OPERATION   FOR   REMOVAL  OF   THE   UTERUS. 

The  uterus  may  be  removed  through  an  abdominal  in- 
cision (abdominal  hysterectomy),  or  it  may  be  removed 
through  the  vagina  (vaginal  hysterectomy).  A  combina- 
tion of  the  two  methods  of  operating  is  sometimes  em- 
ployed. 

In  many  conditions  it  is  not  necessary  to  remove  the 
cervix.  Partial  hysterectomy  or  supra-vaginal  amputa- 
tion of  the  uterus  at  some  convenient  point  of  the  cervix 
may  be  performed. 

Such  supra-vaginal  amputation  of  the  uterus  may  be 
done  in  nearly  all  operations  that  are  not  performed  for 
malignant  disease.  In  sarcoma  or  cancer  the  whole 
uterus  should  be  removed  at  the  vaginal  junction,  and, 
if  necessary,  the  upper  portion  of  the  vagina  should  be 
excised. 

In  the  case  of  fibroid  tumor  and  in  non-malignant  dis- 
ease of  the  body  of  the  uterus  supra-vaginal  amputation 
is  sufficient.     Supra-vaginal  amputation  is  an  easier  and 


SPECIAL   TECHNIQUE  OF  OPERA  TIONS.        509 

safer  operation  than  complete  hysterectomy.  Abdominal 
hysterectomy  is  most  easily  performed  with  the  patient 
in  the  Trendelenburg  position. 

Supra-vaginal  Amputation  of  the  Uterus. — After 
the  abdomen  has  been  opened,  the  ovarian  artery  should 
be  ligated  in  the  infundibulo-pelvic  ligament,  as  in  the 
operation  of  salpingo-oophorectomy.  A  second  ligature, 
or  forceps,  should  then  be  placed  upon  the  ovarian  artery 
at  the  uterine  cornu. 

The  round  ligament  should  then  be  ligatured  with 
medium-sized  silk  at  a  point  situated  about  an  inch  from 


Fig.  213. — Supra-vaginal  amputation  of  the  uterus,  first  step:    ligatures  have 


been  placed  on  the  ovarian  arteries  and  the  round  ligaments. 

the  uterus.  Similar  ligatures  should  then  be  placed  about 
the  ovarian  artery  and  the  round  ligament  on  the  opposite 
side. 

The  infundibulo-pelvic  ligament  immediately  outside 
of  the  abdominal  ostium  of  the  tube,  the  round  liga- 
ment between  the  ligature  and  the  cornu,  and  the  broad 
ligament  as  far  as  the  uterus  should  then  be  divided  with 
scissors  on  each  side. 

The  uterus  is  thus  freed  from  all  its  attachments  down 


5IO     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

to  a  point  somewhat  above  the  level  of  the  internal  os. 
The  vessels  that  remain  to  be  secured  are  the  uterine 
arteries. 

The  peritoneum  is  next  divided  by  a  transverse  incision 
across  the  anterior  face  of  the  uterus,  immediately  below 
the  line  of  reflection  of  the  peritoneum  from  the  uterus 
to  the  bladder.  This  incision  should  join  at  each  end 
the  incisions  that  had  been  previously  made  in  dividing 
the  broad  lio-aments. 


Fig.  214. — Supra-vaginal  amputation  of  the  uterus,  second  step  :  the  broad  liga- 
ments have  been  divided  down  to  the  level  of  the  internal  os  uteri. 


The  bladder  should  then  be  dissected  from  the  anterior 
face  of  the  uterus  and  cervix,  down  to  the  vaginal  junc- 
tion. 

The  bladder  is  but  loosely  attached  to  the  uterus,  and 
may  be  readily  pushed  off  with  the  finger  or  with 
closed  scissors.  The  finger  pressed  out  to  a  short  distance 
on  each  side  of  the  cervix  will  push  away  the  anterior 
layer  of  the  broad  ligament  with  the  bladder,  so  that  the 
uterus  is  perfectly  free  in  front. 


SPECIAL   TECHNIQUE  OF  OPERATIONS.        S^ 

The  posterior  layer  of  the  broad  ligament  and  the 
cellular  tissue  may  then  be  divided,  with  scissors,  along 
the  side  of  the  uterus  down  to  a  point  somewhat  below 
the  level  of  the  internal  os.  This  incision  should  not  be 
made  too  close  to  the  uterus,  or  the  uterine  artery  that 
runs  up  along  side  of  the  uterus  and  cervix  may  be 
divided.  The  operator  should  place  one  or  two  fingers 
upon  the  posterior  aspect  of  the  broad  ligament,  immedi- 
ately beside  the  cervix,  and  while  the  uterus  is  drawn 
upward  should  pass  a  heavy  ligature  beneath  the  tissue 
that  includes  the  iiterine  artery.  The  pulsation  of  the 
uterine  artery  may  usually  be  felt  by  the  finger  placed  be- 
hind the  broad  ligament.  This  ligature  includes  the  cell- 
ular tissue  at  the  base  of  the  broad  ligament,  the  uterine 


I'lG.  215. — bupra-vaginal  amputation  of  the  uterus,  third  step  :  the  peritoneum 
has  been  incised  across  the  anterior  face  of  the  uterus ;  the  bladder  has  been 
dissected  from  the  cervix;  the  bases  of  the  broad  hgaments  have  been  opened; 
the  uterine  arteries  have  been  secured  by  hgatures  placed  between  the  ureters 
and  the  cervix. 


artery,  and  part  of  the  posterior  peritoneal  layer  of  the 
broad  ligament.     It  does  not  pass  through  the  anterior 


512      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

peritoneal  layer  of  the  broad  ligament,  which  had  been 
previously  dissected  away.  The  ligature  should  be  placed 
as  closely  as  possible  to  the  cervix  without  including 
cervical  tissue.  It  should  be  remembered  that  the  ureter 
lies  about  half  an  inch  from  the  side  of  the  normal  cervix 
and  at  the  level  of  the  external  os.  The  ureter  is  usually 
more  remote  than  this  when  the  ligature  is  passed,  be- 
cause the  uterus  is  drawn  upward  and  the  ureter  is  pushed 
aside  by  the  fingers  at  the  side  of  the  cervix. 

The  uterine  artery  should  be  secured  in  a  similar  way 
upon  the  opposite  side. 

The  bases  of  the  broad  ligaments  should  then  be 
divided  with  scissors  between  the  cervix  and  the  ligatures 
of  the  uterine  arteries.  To  prevent  slipping  of  the  liga- 
ture, ample  tissue  should  be  left  between  the  incision  and 
the  ligature.  As  the  cervix  is  not  malignant,  the  incision 
may  be  made  as  close  to  this  structure  as  necessary. 


Fig.  2i6. — Supra-vaginal  amputation  of  the  uterus,  fourth  step:  the  uterus 
has  been  amputated  below  the  level  of  the  internal  os ;  sutures  have  been  intro- 
duced to  close  the  stump  of  the  cervix. 

The  uterus  should  then  be  amputated  by  a  wedge- 
shaped  incision  through  the  cervix,  making  an  anterior 
and  a  posterior  flap. 


SPECIAL    TECHNIQUE  OF  OPERATIONS.        513 

When  the  cervical  canal  is  opened,  it  may  be  immedi- 
ately sterilized  with  a  solution  of  bichloride  of  mercury 
(i  :  500). 

As  the  uterus  is  cut  away  the  flaps  of  the  cervix  are 
secured  with  forceps.  The  cervical  stump  is  usually 
white  and  dry. 

The  flaps  of  the  cervix  should  next  be  united  by  inter- 
rupted silk  suture.  Care  should  be  taken  to  avoid  pass- 
ing a  suture  through  the  cervical  canal,  as  it  might  be- 
come infected. 

The  anterior  peritoneal  layer  of  the  broad  ligament 
and  the  peritoneal  reflection  from  the  bladder  are  then 
drawn  over  the  field  of  operation  and  secured  by  fine  silk 
sutures  to  the  posterior  peritoneal  layer  and  the  posterior 
aspect  of   the  cervix.      The  stump  of   the  cervix,    the 


Fig.  217. — Supra-vaginal  amputation  of  the  uterus,  completed  operation:  the 
anterior  and  posterior  peritoneal  layers  of  the  broad  ligament  have  been  united 
by  sutures;  the  peritoneal  covering  of  the  bladder  has  been  dravi^n  over  and 
sutured  to  the  posterior  aspect  of  the  stump  of  the  cervix. 

stump  of  the  uterine  arteries,  and  the  cellular  tissue  of 
the  broad  ligaments  are  thus  covered  by  peritoneum.  The 
only  raw  surfaces  exposed  are  the  stumps  of  the  ovarian 
arteries  and  of  the  round  ligaments.  These  surfaces  may 
also  be  covered  if  the  operator  so  desires. 


514     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

Complete  Abdominal  Hysterectomy. — In  this  ope- 
ration the  nterus  is  removed  at  the  vaginal  junction.  The 
operation  is  absolutely  necessary  in  cases  of  malignant 
disease  of  the  body  and  neck  of  the  uterus.  It  is  not 
often  necessary  in  the  treatment  of  the  other  conditions 
for  which  hysterectomy  is  performed.  The  operation  re- 
quires a  longer  time  than  the  operation  of  partial  hyste- 
rectomy; it  is  often  accompanied  by  profuse  bleeding 
from  the  edge  of  the  divided  vagina;  there  is  more  danger 
of  injury  to  the  ureters,  and  there  is  more  danger  of  sep- 
tic infection,  because  the  vagina  is  opened;  and,  finally, 
the  operation  very  considerably  shortens  the  vaginal 
canal. 

The  first  steps  in  the  operation  of  complete  hysterec- 
tomy are  the  same  as  those  in  partial  hysterectomy.  In 
the  case  of  malignant  disease  of  the  cervix  the  ligatures 
on  the  uterine  arteries  should  be  placed  as  far  from  the 
cervix  as  possible  without  including  the  ureters. 

Drs.  Kelly  and  Clark  advise  the  preliminary  intro- 
duction of  bougies  into  the  ureters  in  order  to  locate 
these  structures  and  thus  prevent  injury  to  them.  If  the 
operator  is  sure  of  the  position  of  the  ureter,  he  may 
ligate  the  uterine  artery  upon  the  outer  side  of  the  ureter, 
and  carry  the  incision  through  structures  well  outside  of 
the  diseased  cervix 

After  the  vessels  have  been  secured  and  the  bladder 
has  been  separated  from  the  uterus  and  the  upper  part  of 
the  vagina,  and  the  broad  ligaments  have  been  divided 
down  to  the  vagina,  a  transverse  incision  is  made  with 
the  knife  or  scissors  into  the  anterior  vaginal  fornix. 
The  position  of  the  anterior  vaginal  fornix  may  be  deter- 
mined by  palpation  and  percussion.  A  drum-like  sound 
is  obtained  by  snapping  the  finger  upon  the  tense  vaginal 
wall. 

With  the  finger  in  the  opening  in  the  anterior  vaginal 
fornix  as  a  guide,  the  incision  is  continued  around  the 
sides  and  posterior  wall  of  the  vagina.  The  edge  of  the 
vagina  is  secured  by  forceps,  and  bleeding  vessels  in  the 


SPECIAL   TECHNIQUE  OF  OPERATIONS.        515 

walls  are  ligated.  When  hemostasis  is  complete  the 
vagina  is  closed  by  sutures  that  pass  through  the  outer 
portions  of  the  walls,  but  do  not  enter  the  vaginal  canal. 
The  peritoneum  is  then  drawn  over  the  field  of  opera- 
tion and  the  abdomen  is  closed.  If  hemostasis  is  not 
perfect,  gauze  drainage  through  the  vagina  or  the  abdom- 
inal incision  must  be  employed. 

Some  operators  do  not  ligate  the  uterine  arteries  until 
the  vagina  has  been  opened.  The  ovarian  arteries  are 
secured,  the  bladder  is  separated  from  the  uterus  and  the 
upper  part  of  the  vagina,  and  the  broad  ligaments  are 
divided  down  to  a  point  somewhat  below  the  level  of  the 
internal  os. 

The  anterior  vaginal  fornix  is  then  opened,  and  the 
incision  is  carried  around  toward  the  lateral  fornices  as 
far  as  may  be  done  without  injury  to  the  uterine  arteries. 
The  uterus  is  then  drawn  forward  and  the  posterior  vag- 
inal fornix  is  opened,  the  finger  introduced  through  the 
opening  into  the  anterior  fornix  acting  as  a  guide. 

The  uterus  is  now  attached  to  the  body  only  by  two 
lateral  bands  of  tissue  that  include  the  cellular  tissue  at 
the  base  of  the  broad  ligament,  the  uterine  artery,  and  a 
strip  of  vaginal  mucous  membrane  over  the  lateral  vag- 
inal fornix.  This  band  of  tissue,  exclusive  of  the  vag- 
inal mucous  membrane,  is  then  secured  by  a  ligature  that 
does  not  enter  the  vagina,  but  passes  immediately  above 
the  strip  of  vaginal  mucous  membrane.  A  finger  intro- 
duced into  the  vagina  serves  to  guide  the  ligature-needle. 
The  uterus  may  then  be  cut  away. 

The  ligatures  of  the  uterine  arteries  are  sometimes  left 
long,  the  ends  being  carried  down  into  the  vagina  and  a 
gauze  drain  being  introduced  into  the  vagina,  the  upper 
portion  of  the  drain  reaching  just  above  the  level  of  the 
stump  of  the  uterine  arteries. 

The  peritoneum  may  be  left  open,  or  it  may  be  drawn 
over  the  drain  and  the  field  of  operation  as  already  de- 
scribed. 

Drainage  through  the  vagina  in  this  way  is  advisable 


5i6     A  TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

if  the  hemostasis  be  not  perfect  and  if  the  operator  fears 
septic  infection. 

In  hysterectomy  for  cancer  of  the  cervix  it  is  usually 
advisable  to  remove  as  much  as  possible  of  the  cancerous 
mass  by  a  preliminary  operation  two  or  three  days  before- 
hand. The  diseased  tissues  should  be  cut  away  with  the 
knife,  scissors,  and  the  sharp  curette,  the  cavity  seared  . 
with  the  thermo-cautery,  and  closed  by  approximation  of 
the  edges  with  a  few  silk  sutures.  The  dangers  of  septic 
infection  and  of  transplantation  of  cancer-cells  during  the 
hysterectomy  are  thus  diminished. 

The  surgeon  should  always  keep  in  mind  the  possibility 
of  the  transplantation  of  cancer-cells  from  diseased  into 
healthy  tissues.  It  seems  very  probable  that  some  cases 
of  recurrence  have  been  due  to  this  cause.  During  hys- 
terectomy the  operator  should  therefore  avoid,  as  much 
as  possible,  cutting  into  or  manipulating  the  cancer  mass. 
Instruments,  such  as  hemostatic  forceps  and  volsella  for- 
ceps, which  have  grasped  diseased  tissue,  should  not  be 
used  upon  healthy  tissue  without  previous  sterilization; 
and  sponges  and  pads  which  have  been  in  contact  with 
the  cancerous  tissue  should  be  discarded. 

The  methods  of  operating  just  described,  modified  to 
meet  special  indications,  are  applicable  to  all  cases  in 
which  hysterectomy  is  required. 

Sometimes,  in  cases  of  fibroid  tumor,  the  broad  liga- 
ment is  very  much  hypertrophied  and  contains  enormous 
veins,  and  additional  ligatures  besides  those  on  the  ova- 
rian and  uterine  arteries  are  required.  It  is  often  neces- 
sary to  place  a  large  number  of  forceps  upon  bleeding 
vessels  on  the  surface  of  the  tumor  as  it  is  cut  away  from 
the  broad  ligament. 

The  anatomical  relations  are  often  very  much  dis- 
turbed, and  it  may  be  impossible  to  determine  the  posi- 
tion of  the  cervix  and  the  uterine  arteries  until  the 
greater  part  of  the  tumor  has  been  freed  from  its  connec- 
tions. Sometimes  the  tumor  so  fills  the  pelvis  that  it  is 
impossible  to  ligate,  at  first,  both  ovarian  arteries.     The 


SPECIAL   TECHNIQUE  OF  OPERATIONS.        5^7 

operator  must  first  attack  the  more  accessible  side,  ligate 
the  ovarian  artery,  cut  away  the  broad  ligament,  strip 
ofF  the  bladder,  ligate  the  uterine  artery,  and  perhaps 
divide  the  cervix,  before  he  proceeds  to  the  other  side. 
Bleeding  from  the  tumor  must  be  controlled  by  the  care- 
ful application  of  forceps  or  ligatures.  An  inaccessible 
uterine  artery  is  sometimes  most  readily  reached  in  this 
way  from  below,  after  the  attachments  upon  the  opposite 
side  have  been  divided  and  the  cervix  has  been  ampu- 
tated. Some  operators  perform  hysterectomy  in  all  cases 
by  ligating  and  cutting  away  from  above  downward 
on  one  side — the  more  accessible — then  cutting  across 
the  cervix,  and  ligating  and  cutting  away  on  the  opposite 
side  from  below  upward. 

The  difficulties  are  greatest  in  the  case  of  intra-liga- 
mentous  fibroids.  Such  operations  are  among  the  most 
difficult  in  surgery.  The  directions  given  for  the  treat- 
ment of  intra-ligamentous  cysts  are  applicable  also  to  this 
condition.  The  surgeon  should  always  at  first  secure  the 
ovarian  arteries  if  possible.  He  should  then  incise  the 
peritoneal  investment  across  the  anterior  or  posterior  face 
of  the  tumor. 

Enormous  veins  often  lie  immediately  beneath  the  peri- 
toneum, and  care  must  be  taken  to  avoid  injuring  them. 

The  peritoneum  should  be  stripped  off  with  the  fingers 
or  with  blunt  scissors.  Bleeding  vessels  are  secured  with 
forceps  as  they  appear.  No  attaching  structures  should 
be  divided  until  they  have  been  carefully  examined,  for 
all  anatomical  relations  are  distorted  by  these  growths. 
The  ureter  may  pass  over  the  top  of  the  tumor,  far  re- 
moved from  its  normal  position  on  the  pelvic  floor. 

After  the  surgeon  has  started  the  enucleation  of  a 
tumor  of  this  kind  he  must  complete  the  operation. 
Bleeding  cannot  be  arrested  until  the  tumor  has  been 
enucleated,  the  cervix  exposed,  and  the  uterine  arteries 
secured. 

The  operation  is  often  accompanied  by  very  profuse 
hemorrhage,  but  this  hemorrhage  is  always  arrested  by 


5i8      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

the  ligature  of  the  ovarian  and  uterine  arteries,  which 
alone  supply  the  growth.  The  surgeon  should  therefore 
not  delay  the  operation  by  the  ligature  of  separate  bleed- 
ing points  until  the  main  vessels  have  been  secured. 

Vaginal  Hysterectomy. — Vaginal  hysterectomy  may 
be  performed  for  the  relief  of  any  condition  in  which 
the  uterus  or  attached  tumor  is  sufficiently  small  to  pass 


Fig.  2i8. — Lateral  vaginal  retractor. 

through  the  vagina.  The  operation  is  very  popular  with 
some  surgeons.  It  is  but  rarely  used  by  the  writer.  The 
difficulty  in  dealing  with  adhesions  and  other  complica- 
tions in  the  upper  part  of  the  pelvis  seems  to  be  much 
less  when  the  operation  is  performed  through  an  abdom- 
inal incision. 

The  technique  of  vaginal  hysterectomy  varies  con- 
siderably in  the  hands  of  different  operators.  The  vag- 
inal vault  is  opened  with  the  knife,  the  scissors,  or  the 
cautery.  The  vessels  of  the  broad  ligament  are  secured 
with  the  ligature  or  with  the  clamp.  The  uterus  is 
sometimes  divided  by  longitudinal  incision  and  the  halves 
are  separately  removed. 

The  following  are  the  general  directions  for  the  per- 
formance of  the  operation: 

The  woman  is  placed  in  the  lithotomy  position.  The 
vagina  is  opened  with  the  Sims  speculum  and  with  lateral 
vaginal  retractors  (Fig.  318). 

If  the  cervix  is  septic,  it  is  thoroughly  curetted,  steril- 
ized with  the  cautery  or  by  other  means,  and  the  sides  of 
the  excavation  are  united  by  suture. 


SPECIAL   TECHNIQUE  OF  OPERATIONS.        519 

The  cervix  is  seized  by  tenaculum  forceps  and  dragged 
downward  and  forward. 

A  transverse  incision  with  knife,  scissors,  or  cautery  is 
made  in  the  posterior  vaginal  fornix,  and  Douglas's  pouch 
is  opened. 

A  sponge  is  introduced  into  the  peritoneum  behind 
the  uterus. 


P^IG.  219. — Vaginal  hysterectomy  with  clamps:  first  step  (Baldy). 


Some  operators  suture  the  posterior  peritoneal  layer  of 
Douglas's  pouch  to  the  posterior  vaginal  wall,  to  control 
bleeding  and  to  prevent  stripping  of  the  peritoneum. 

The  cervix  is  now  dragged  backward  and  a  transverse 
incision  is  made  across  the  anterior  vaginal  fornix. 

The  bladder  is  carefully  dissected  from  the  anterior 


520     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

face  of  the  cervix  with  the  knife,  scissors,  and  finger, 
and  the  utero-vesical  fold  of  peritoneum  is  opened.  The 
peritoneum  and  the  anterior  vaginal  wall  may  here  also 
be  united  by  suture. 

An  incision  may  then  be  made  through  the  vaginal 
mucous  membrane  of  the  lateral  fornices,  uniting  the 
anterior  and  posterior  incisions. 


Fig.  220. — Vaginal  hysterectomy  with  clamps  :  second  step  (BaldyV 


With  a  finger  in  Douglas's  pouch  as  a  guide,  the  broad 
ligaments  are  then  secured  in  successive  portions  by  liga- 
ture or  by  strong  clamp  forceps,  and  the  uterus  is  cut  away 
with  the  scissors  as  the  ligatures  or  clamps  are  placed. 

As  the  upper  portion  of  the  broad  ligaments  is  reached 
the  procedure  may  be  facilitated  by  retroverting  or  ante- 


SPECIAL   TECHNIQUE  OF  OPERATIONS.        521 

verting  the  uterus,  the  fundus  being  dragged  through  the 
posterior  or  the  anterior  incisions  in  the  vaginal  vault. 

The  tubes  and  ovaries  should  be  removed  when  possi- 
ble, especially  in  the  case  of  malignant  disease. 

After  the  uterus  has  been  removed  the  vagina  may  be 
packed  with  a  gauze  drain  that  reaches  upward  between 
the  stumps  of  the  uterine  arteries;  or,  if  ligatures  have 


Fig.  221.— Vaginal  hysterectomy  with  clamps:   third  and  final  step  (Baldy). 

been  used,  the  vaginal  vault  may  be  closed.  The  for- 
mer procedure  is  the  safer.  When  the  gauze  drain  is 
used,  it  is  advisable  to  leave  the  ends  of  the  ligatures  on 
the  uterine  arteries  long  and  protruding  into  the  vagina. 
The  ligatures  usually  become  infected,  and  their  removal 
is  facilitated  by  this  procedure.  If  clamps  are  used,  they 
should  be  removed  in  forty-eight  hours. 


522      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

The  treatment  after  vaginal  hysterectomy  is  the  same 
as  that  already  described  after  celiotomy. 

Combined  Vaginal  and  Abdominal  Hysterec- 
tomy.— A  combined  vaginal  and  abdominal  operation  is 
sometimes  performed  in  order  to  enable  the  surgeon  to 
deal  with  adhesions  and  other  complications  in  the  upper 
part  of  the  pelvis. 

The  operation  is  usually  begun  below.  The  vaginal 
connections  and  the  bladder  are  separated  from  the  ute- 
rus, and  the  bases  of  the  broad  ligaments  are  secured 
with  the  ligature  or  the  clamp;  the  cervix  is  freed  from 
its  attachments  to  the  broad  ligament. 

The  abdomen  is  then  opened  and  the  operation  is  fin- 
ished from  above,  the  uterus  being  removed  through  the 
abdominal  incision. 

The  writer  performs  the  combined  operation  in  the  re- 
verse order,  as  follows: 

The  abdomen  is  first  opened.  The  ovarian  arteries 
and  the  round  ligaments  are  secured  by  ligature.  The 
bladder  is  separated  from  the  uterus  and  the  upper  part 
of  the  vagina.  The  broad  ligaments  are  divided  to  a 
point  somewhat  below  the  level  of  the  internal  os. 

A  gauze  pad  is  then  introduced  to  the  bottom  of  Doug- 
las's pouch,  and  another  to  the  bottom  of  the  space  be- 
tween the  uterus  and  the  bladder.  The  abdominal  incis- 
ion is  then  closed. 

The  rest  of  the  operation  is  performed  through  the 
vagina.  The  posterior  and  anterior  vaginal  fornices  are 
opened  by  incisions  made  directly  upon  the  gauze  pads. 
The  vaginal  mucous  membrane  is  divided  over  the  vag- 
inal fornices  by  an  incision  that  joins  the  anterior  and 
posterior  incisions  in  the  vaginal  vault.  The  bases  of  the 
broad  ligaments  are  secured  by  strong  clamp-forceps,  and 
the  uterus  is  cut  away  and  removed  through  the  vagina. 
The  gauze  pads  are  then  removed,  and  the  vagina  is 
drained  with  gauze  introduced  as  far  as  the  upper  end  of 
the  forceps. 


SPECIAL   TECHNIQUE  OF  OPERA  TIONS.        523 

The  following  are  the  advantages  of  the  latter  method 
of  operating: 

If  sterilization  of  the  vagina  and  the  cervix  is  not  per- 
fect, the  cleaner  part  of  the  operation  is  performed  first. 
The  bladder  is  more  easily  separated  from  the  uterus  by 
operating  from  above  than  by  way  of  the  vagina.  The 
vaginal  vault  is  quickly  and  safely  opened  by  incisions 
made  upon  the  gauze  pads,  which  keep  the  intestines 
out  of  the  way. 

The  uterus  and  the  infected  cervix  are  removed  through 
the  vagina,  and  not  through  the  abdominal  cavity. 

If  the  operation  is  performed  for  cancer  of  the  cervix, 
the  incision  is  made  more  accurately  beyond  the  limits 
of  the  disease  if  the  vaginal  vault  is  opened  through  the 
vagina  than  if  it  is  opened  from  above. 

Werder,  of  Pittsburg,  has  advised  the  following  com- 
bined operation:  The  abdomen  is  opened,  and  the  uterus, 
tubes,  and  ovaries  are  freed  as  in  ordinary  hysterectomy. 
The  ureters  are  dissected  out,  and  the  uterine  arteries 
are  ligated  near  their  origin.  The  bladder  is  entirely 
freed  from  the  uterus,  and  also,  for  a  considerable  dis- 
tance, from  the  vagina.  The  recto-vaginal  space  is 
then  opened,  and  the  posterior  vaginal  wall  is  stripped 
from  the  rectum  as  far  down  as  necessary.  The  lateral 
vaginal  attachments  are  loosened.  The  uterus  and 
vagina  are  then  pushed  down  into  the  pelvic  outlet,  and 
the  peritoneum  from  the  anterior  pelvic  wall  is  united 
with  that  covering  the  rectum,  thus  shutting  off  the 
pelvis  from  the  general  peritoneal  cavity  and  covering 
all  raw  surfaces  with  peritoneum.  The  abdomen  is  then 
closed. 

The  patient  is  then  placed  in  the  lithotomy  position. 
The  uterus — which  is  found  protruding  at  the  vulva — is 
seized  with  volsella  forceps  and  drawn  completely  out  of 
the  vulvar  orifice  with  the  inverted  vagina.  With  the 
finger  in  the  rectum  and  the  sound  in  the  bladder  as 
safeguards  against  injuring  these  organs,  the  inverted 
vagina   is   amputated   with    the    knife   or   the   thermo- 


524      A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

cautery.  The  chief  advantage  of  this  operation  is  that 
a  large  vaginal  cnflf  may  be  removed. 

Abdominal  Myomectomy. — In  some  cases  of  uterine 
fibroid  it  is  proper  to  remove  the  tumor  without  taking 
away  the  uterus.  This  operation — myomectomy — is  per- 
formed as  follows  : 

The  abdomen  is  opened  by  a  free  incision,  the  pelvis 
is  elevated,  and  the  intestines  are  displaced  from  the 
pelvic  cavity  in  the  usual  manner.  The  tumor  and  the 
uterus  are  surrounded  by  gauze  sponges,  and,  where  pos- 
sible, should  be  brought  outside  the  abdominal  cavity. 
An  incision  is  made  around  the  pedicle  or  through  the 
capsule  of  the  tumor,  and  it  is  enucleated  by  dissection 
with  the  sharp  or  the  blunt  end  of  the  scalpel.  During 
the  operation  hemorrhage  may  be  controlled  by  an  assis- 
tant, who  compresses  with  his  fingers  the  vessels  on  each 
side  of  the  uterus,  or  by  placing  a  temporary  rubber  liga- 
ture about  the  cervix  uteri. 

Hemostasis  is  effected  and  the  wound  in  the  uterus  is 
closed  by  layers  of  continuous  or  interrupted  catgut 
sutures.  Great  care  should  be  taken  to  prevent  hemor- 
rhage between  the  layers  of  suture,  and  to  insure  accu- 
rate closure  of  the  incision  in  the  uterus.  The  tem- 
porary ligature  about  the  cervix,  or  the  compression  of 
the  vessels  of  the  broad  ligaments,  should  be  removed 
from  time  to  time  during  the  process  of  suturing  and 
after  closure  of  the  uterine  wound,  in  order  to  determine 
the  position  of  bleeding  points  and  the  efficiency  of  the 
hemostasis  ;  and  before  closing  the  abdominal  incision 
the  uterine  wound  should  be  inspected  for  several 
minutes  while  the  woman  is  in  the  horizontal  position. 

The  abdomen  may  usually  be  closed  without  drain- 
aofe. 


CHAPTER   XLIII. 

THE    EFFECT  OF  THE  REMOVAL  OF  THE  UTERINE 
APPENDAGES. 

Removal  of  the  tube  and  ovary  upon  one  side  has  no 
effect  upon  menstruation  or  upon  any  of  the  other  cha- 
racteristics of  the  woman. 

Removal  of  the  tubes  and  ovaries  upon  both  sides  is 
followed  within  forty-eight  hours  by  slight  bleeding  from 
the  uterus,  lasting  for  one  or  two  days. 

If  the  removal  of  the  tubes  and  ovaries  has  been  com- 
plete, menstruation,  in  the  majority  of  cases,  never  re- 
appears. 

In  a  few  cases  menstruation  appears  for  one,  two,  or 
three  periods  after  the  operation,  usually  in  diminished 
amount,  and  then  ceases  for  ever.  Tn  some  other  cases 
there  is  a  period  of  a  few  months  of  amenorrhea,  fol- 
lowed by  two  or  three  scanty  menstrual  flows,  before  the 
bleeding  permanently  ceases. 

These  phenomena,  it  will  be  observed,  are  similar  to 
those  of  the  normal  menopause. 

The  woman  after  double  salpingo-oophorectomy  expe- 
riences the  nervous  and  gastro-intestinal  disturbances 
that  so  usually  accompany  the  menopause.  She,  in  fact, 
passes  through  a  premature  menopause,  the  phenomena 
of  which  may  persist  for  one  or  two  years. 

The  secondary  sexual  characteristics  of  the  woman — the 
voice,  the  figure,  and  the  growth  of  hair — are  not  altered 
if  the  appendages  are  removed  during  adult  life.  The 
case  may  be  different  if  the  appendages  are  removed  in 
the  undeveloped  girl,  in  whom  the  ovarian  influence  is 
essential  for  complete  development. 

The  woman  loses  none  of  her   feminine   attractions. 

525 


526     A   TEXT-BOOK  OF  DISEASES  OF  WOMEN. 

She  may,  indeed,  become  better-looking  if  the  operation 
has  relieved  chronic  suflfering.  It  is  said  that  Gyges, 
king  of  Lydia,  caused  the  removal  of  ovaries  from  wom- 
en with  a  view  to  prolonging  their  charms. 

Double  oophorectom)*  may  be  followed  by  obesity  if 
the  woman  have  a  tendency  to  form  fat.  The  relief  of 
suffering  and  the  consequent  improved  nutrition  favor  the 
development  of  obesity.  There  seems  to  be  nothing  in- 
herent in  the  operation  to  cause  it.  Many  women  remain 
thin  after  the  operation. 

The  emotions  of  the  woman  are  unaltered  by  double 
oophorectomy,  with  the  exception  of  some  cases  in  which 
the  sexual  desire  is  destroyed.  Sexual  desire  is  depend- 
ent upon  such  a  variety  of  conditions,  both  within  and 
without  the  woman,  that  it  is  difficult  to  determine  the 
amount  of  influence  that  removal  of  the  ovaries  exerts 
upon  this  feeling. 

It  is  undoubtedly  true  that  sexual  desire  is  sometimes 
destroyed  by  the  operation.  On  the  other  hand,  the  sex- 
ual desire  is  very  often  restored  by  the  operation,  which 
relieves  the  former  dyspareunia,  or  painful  coitus. 


INDEX. 


Abdomen,  binder  for,  471 

distention  of,  after  celiotomy,  489 

drainage  of,  472,  475 

enlargement  of,  21 

examination  of,  21,  23,  24,  30 

exploration  of,  481 

fluctuation  in,  22 

protection    oif    contents    of,    during 
operation,  481 

retentive  power  of,  97 

sterilization  of,  for  operation,  465 
Abdominal  incision,  closing  of,  483 

irrigation,  temperature  of  water  for, 
460 

myomectomy,  252 
technique,  520,  523 

operations,  dressing  of,  471 
instruments  for,  467 

section,  after-treatment  of,  486 

surgery,  training  for,  453 

suture,  layer  method,  485 

sutures,  removal  of,  484 

wall,  incision  of,  479 

closing  of,  483 
Abortion  by  uterine  sound,  37 

in  endometritis,  204 
Abscess,  pelvic,  299 

of  vulvo-vaginal  glands,  40,  42 
Actinomycosis  of  tubes,  309 
Adeno-carcinoma  of  cervix,  179 
Adenoma  of  ovary,  350 

of  tubes,  309 

of  uterus,  malignant,  219 
Adhesions  of  clitoris,  49 

pelvic,  treatment,  501,  504 
Alexander's  operation,  140 
Amenorrhea,  398 

emansio  mensium,  398 

in  superinvolution,  215 

in  tubal  pregnancy,  320 

pelvic  massage  in,  406 

periodical  disturbances  in,  399 

suppressio  mensium,  398 
Ampullar  pregnancy,  31 1 
Anesthesia,  462 
Anesthetizer,  duties  of,  462 


Animals,  disease  of  reproductive  organs 

in,  17 
Anteflexion  of  uterus,  1 17 

causes,  117,  120 

menstruation  in,  120 

miscarriage  in,  121 

pessaries  in,  121 

pregnancy  in,  121 

sequelae,  120 

sterility  in,  120 

symptoms,  120 

varieties,  118 
Anterior  colporrhaphy,  88 
Antiseptics,  action  of,  on  peritoneum, 

449 
Apoplexy  of  ovary,  342 
Apparatus  for  gynecological  operations, 

454 
Appendix    vermiformis,    palpation   of, 

23 
Applicator,  vesical,  418 
Arnold's  sterilizer,  458 
Ascites  in  ovarian  cyst,  362 

in  solid  tumors  of  ovary,  387 
Asepsis,  importance  of,  in  gynecology, 

450 
Atresia  of  cervix,  19 

of  vagina,  19 
Auscultation  of  abdomen,  24 

Barnes'  bag  in  inversion,  265 
Bartholin's  glands,  38 
Basham's  mixture,  169 
Basins,  sterilization  of,  455 
Bimanual  examination,  25—27,  30 
in  carcinoma  of  uterus,  222 
in  endometritis,  204 

reposition  of  uterus,  133 
Binder,  abdominal,  471 
Bivalve  speculum,  31,  32 
Bladder,  base  of,  428 

body  of,  428 

catheterization  of,  431 

cervix  of,  428 

dissection  of,  from  uterus,  510 

empty,  428 

527 


528 


INDEX. 


Bladder,  examination  of,  36,  419 

fundus  of,  428 

intia-ureteral  ligament  of,  429 

irrigation  of,  435 

irritable,  87 

meatus  intern  us,  situation  of,  437 

mucous  membrane  of,  428 

neck  of,  428 

structure  of,  428 

trigone  of,  428 

vascular  supply  of,  429 

vesical  triangle  of,  428 
Blaud's  pill,  168 
Boldt's  table,  454 
Bowels,  treatment  of,  after  celiotomy, 

488 
Braun's  colpeurynter,  116 
Broad  ligament,  hematoma  of,  314 
Bulbo-cavernosus,  57 
Buried  sutures,  485 

Calculi  in  vesico-vaginal  fistula,  408 

vesical,  438 
Calibrator,  urethral,  416 
Canal  of  Gartner,  54 

of  Nuck,  44 
Carcinoma,  cachexia  of,  190 
of  cervix,  179 

adeno-carcinoma,  179 

broad  ligaments  in,  183,  191,  192 

caustics  in,  194 

diagnosis  from  lupus,  186 

from  syphilitic  ulceration,  186 
from  uterine  polyp,  186 

duration,  191 

hysterectomy  for,  191,  192 
remote  results,  193 

metastasis  in,  183 

origin,  179 

peritoneal  involvement  in,  183 

septic  infection  in,  190 

squamous-cell,  179 

symptoms,  187 

treatment,  191,  I93 

ulceration  in,  180 

ureteral  involvement  in,  183 

urinary  fistulas  in,  183 

varieties,  179,  181,  182 
of  Fallopian  tubes,  218 
of  ovaries,  218 
of  peritoneum,  218 
of  ureters,  183 
of  uterus,  body  of,  216 

age,  218 

causes,  219 

curette  in,  222 

in  lower  animals,  17 

influence  of  fibroids  in,  219 

leucorrhea  in,  221 


Carcinoma  of  uterus,  metastasis  in,  218, 
221,  222 
operation  in,  222,  223 
symptoms,  220 
of  vagina,  54 
urethral,  428 
Carrier  for  perineal  sutures,  64 
Caruncle,  urethral,  426 
results,  427 
symptoms,  427 
treatment.  427 
Catarrh  of  cervix,  164 
Catgut,  sterilization  of,  469,  470 
Cumol  method,  470 
Reverdin's  method,  470 
Catheter,  Skene's,  422 
Catheterization  after  celiotomy>  487 
as  cause  of  cystitis,  430 
before  operation,  466 
of  bladder,  431 
Celibacy  a  cause  of  disease,  20 

fibroids  in,  20 
Celiotomy,  301,  304 

abdominal  distention  after,  489 
after-treatment,  486 

of  bowels,  487 
catheterization  after,  487 
death  after,  492 
dressings  after,  470 
food  after,  488 
hemorrhage  after,  492 
micturition  after,  487 
mortality  after,  493 
opium  after,  487 
pain  after,  487,  489 
peritonitis  after,  492 
pulse  after,  490 
shock  after,  490 
temperature  after,  490 
thirst  after,  486 
urinary  secretion  after,  488 
vomiting  after,  489 
water  after,  486 
Cellulitis,  pelvic,  299 
Cervical  catarrh,  1 5 1,  164 
erosion  in,  165 
in  displacements,  165 
in  laceration  of  cervix,  150 
sclerosis  in,  165 
Cervix,  amputation  of,  160,  161 
conception  after,  163 
in  subinvolution  of  uterus,  214 
in  uterine  prolapse.  III 
applications  to,  170 
artery  of,  496 
atresia  of,  19 

carcinoma  of,  179-     See  also  Carci- 
noma. 
chancre  of,  178 


INDEX. 


529 


Cervix,  congenital  erosion  of,  172 
split  of,  175 
cystic  degeneration  of,  150,  153 
dilatation  of,  122 
results  of,  1 24 
direction  of,  93 
distance  of,  from  coccyx,  93 
ectropion  of,  148,  150,  157 
endometritis  of,  164 
erosion  of,  after  laceration,  174 
erosions  of,  150,  153 
eversion  in  laceration  of,  148 
examination  of  discharge  from,  444 
gonorrhea  of,  443 
hypertrophic  elongation  of,  176 
in  infancy,  117 
laceration  of,  146 
diagnosis  of,  152 

from  congenital  ectropion,  174 
Nabothian  cysts  in,  150,  182 
reflex  symptoms,  152 
sclerosis  in,  150 
suljinvolution  in,  150 
symptoms,  151 
trachelorrhaphy  in,  154 
treatment,  154 
ulceration  in,  150 
varieties,  148 
with  endometritis,  151 
of  bladder,  428 
patulous  canal,  204 
polypi,  176 
polypoid  growths,  180 
sensation  of,  29 

supra-vaginal  elongation  of,  102 
tuberculosis  of,  1 78 
ulceration  of,  180 
vegetating  growths  of,  180 
Chancre  of  cervix,  178 
Circular  artery,  ligation  of,  1 94 
Clitoris,  adhesions  of,  49 
Clothing  as  cause  of  disease,  19 
Colpeuiynter,  Braun's,  ir6 
Colporrhaphy,  anterior,  88 
Conception  after  amputation  of  cervix, 
163 
after  salpingo-oophorectomy,  503 
Corpora  fibrosa,  386 
Corpus-luteum  cyst,  348 
Cumul  method  for  sterilization  of  cat- 

.  gut,  470 
Curette  in  endometritis,  205,  206,  295 
in  uterine  cancer,  222 
Martin's,  207 
perforation  by,  208 
re]>arative  process  after  use  of,  210 
Sims,  207 
Cyst,  intrn-ligamentous,  removal  of,  505 
Nabothian,  150 


Cyst  of  hernial  sac,  44 
of  Morgagni,  365 
of  ovary,  17.     See  also  Ovary. 
of  round  ligament,  44 
of  vagina,  53 
of  vuivo-vaginal  gland,  42 
trocar,  469 
urethral,  427 
Cystitis,  87 
chronic,  430 
causes,  430,  431 
cystotomy  in,  436 
diagnosis,  431 
effect  on  system,  31 
hypertrophy  of  bladder-wall  in,  430 
use   of    endoscope    in,   432,   434 
436 
obstruction  of  vesical  orifice,  430 
result  of  lacerated  perineum,  432 

of  uterine  displacement,  432 
symptoms,  431 
treatment,  432,  436 
ureter  and  l<idney  involvement,  430 
urinary  changes,  430 
Cystocele,  86, 105 

Sims'  operation  for,  89 
Stoltz's  operation  for,  89 
Cystoscope,  417 
Cystotomy,  436,  437 

Death  after  celiotomy,  492 
Depressor  for  vagina,  31 
Dermoid  cysts,  355 
of  ovary,  503 

age  of  occurrence,  355 
Developmental  errors  a  cause  of  dis- 
ease, 19 
Diarrhea,  vicarious,  401 
Dilatation  of  cervix,  122 
Dilator,  cervical,  121 

vaginal,  408 
Diseases  of  women,  causes  of,  18 
Dorsal  position,  33 
Drainage,  abdominal,  by  gauze,  475 
by  tube,  472 
ill-effects  of,  477 
indications  for,  476 
object  of,  477 
vaginal,  472,  479 
Drainage-tube,  472,  474 
cleansing  of,  473 
syringe  for,  473 
Dressings    for    abdominal    operations, 
470 
sterilization  of,  458 
Duclv-bill  speculum,  31 
Dysmenorrhea  in  anteflexion  of  uterus,. 
119 
in  salpingitis,  287 


530 


INDEX. 


Dysmenorrhea,  membranous,  210 
menstruation  in,  208 

Ectropion,  cervical,  150 
Edebohl's  stnTups,  24 
Elephantiasis  Arabum,  49 
of  vulva,  49 
syphilitic,  49 
Emansio  mensium,  398 
Emmet's  operation  for  lacerated  peri 
neuni,  78 
perineal  needles,  63 

scissors,  62 
treatment    for    inversion    of    uterus, 
265,  266 
Endometritis,  abortion  in,  204 
acute,  197 
cervical,  164 
chronic,  199,  205 
causes  of,  205 
curette  in,  206 
examination  in,  204 
exfoliative,  210 
fungous,  201 
gonorrheal,  197 
in  exanthemata.  197 
in  lacerated  cervix,  15 1,  202 
in  subinvolution,  202 
in  tubal  disease,  202 
influence  on  menstruation,  202 

with  metritis,  197 
ovarian  disease  in,  202 
pain  in,  203 
post-climacteric,  21 1 
puerperal,  197,  19S 
senile,  211 
sterility  in,  204 
structural  changes  in,  201 
with  uterine  displacement,  129,  202 
Endoscope,  425 

in  cystitis,  432,  434,  436 
Enterocele,  90 

Erosion  of  cervix,  150,  172,  174 
Eruptive  fever  as  cause  of  disease,  336 
Exanthemata  as  cause  of  chronic  pelvic 
disease,  198 
of  cystitis,  431 

of  sexual  ill-development,  198 
vaginitis  in,  51 
External  genitalia,  examination  of,  24, 

28 
Extra-uterine    pregnancy,    310.       See 
also  Tubal  pregnancy. 

Facies  ovariana,  377 
Fallopian  tubes,  268 

actinomycosis  of,  30 

adenoma  of,  309 

anatomy  of,  268 


Fallopian  tubes,  cancer  of,  309 
cysts  of  Morgagni,  272 
development  of,  391 
examination  of,  27 
gummata  of,  309 
inflammation    of,   272.     See    also 

Salpingitis. 
miliary  tuberculosis  of,  304 
myoma  of,  309 
pregnancy    in,    310.       See     also 

Ttibal  pregnancy. 
tubercle  of,  303 
tuberculosis  of,  302,  305,  308 

unsuspected,  304 
Fibroid  tumors,  anatomic  changes,  232 
hysterectomy  in,  515 
in  Africans,  18 
in  animals,  17 
in  celibacy,  20 
of  uterus,  227 

and  ovarian  cyst,  244 

and  pregnancy,  244,  252 

appearance  of,  229 

circulatory  abnormalities  in,  242 

degenerations  of,  234,  235 

diagnosis  of,  242,  244 

duration  of  life  in,  233 

frequency  of,  238 

gangrene  in,  235 

hemorrhage  in,  239 

hypertrophy  in,  239 

hysterectomy  in,  251 

in  menopause,  239 

interstitial,  229 

intra-ligamentous,  229,  232,516 

intra-uterine  polyp,  231,  253 

ligation    of   uterine    arteries  in, 
248 

lymphangiectatic,  235 

menstruation  in,  238,  239,  246 

myomectomy  in,  252 

pressure-symptoms  of,  241 

polypoid,  253 

procreative      abnormalities     in, 
237,  247 

prognosis  in,  245 

salpingo-o5pliorectomy  in,  249 

sarcoma  of,  236 

submucous,  229,  231 

subperitoneal,  229 

telangiectatic,  235 

treatment  of,  246,  248 
of  vagina,  54 
recurrent,  225 

inversion  of,  225 

metastasis  in,  225 

tubal  changes  in,  234 
sterility  in,  20 
with  cancer,  225 


INDEX. 


531 


Fibroma,  ovarian,  386 
Fibro-myoma  of  uterus,  225 
Fibro-sarcoma  of  uterus,  225 
Fissure,  vesico-uretliral,  424 
Fistula  in  salpingitis,  286 

needles  for,  410 

of  vulvo-vaginal  glands,  41 

recto-vaginal,  413 

uretero-vaginal,  413 

urethro-vaginal,  412 

vesico-uterine,  413 

vesico- vaginal,  404 
Flatus  after  abdominal  section,  489 
Floating  kidney,  23 
P'luctuation,  abdominal,  22 
Follicular  vulvitis,  38 
Food  after  celiotomy,  488 
Forceps,  bladder,  416 
Four  chlorides,  169 
Fungous  endometiitis,  201 

Gartner's  canal,  54 

duct,  364 
Gauze  sponges,  preparation  of,  460 
Genital  fistulge,  404 

tract,  septic  infection  of,  19 
Genitalia,  development,  391 

examination,  24 

inflammation  of  glands  of  external, 
446 

malformations  of,  391 

preparations  of,  for  operation,  464 
Genu-pectoral  position,  34 
Glands  of  Bartholin,  38 

of  Skene,  419 
Gloves,  rubber,  457 
Gonococci  in  gonorrhea,  442 
Gonococcus,  resistance  to,  443 

of  vagina,  445 
Gonorrhea,  440 

a  cause  of  disease,  19,  39,  442 

auto-infection,  445 

best  time  for  examination,  447 

carbolic  acid  in,  448 

curettement  in,  448 

ejiidemics  of,  442 

gonococci  in,  442 

in  children,  442 

liability  to,  443 

of  cervix  uteri,  443,445 
examination,  444 
of  discharge,  444 

of  rectum,  442 

of  urethra,  443 

of  vagina,  445 
symptoms  of,  446 

of  vulva,  446 

persistence  of,  443 

results  of,  19 


Gonorrheal  endometritis,  445 
macula,  41 
vaginitis,  445 
Green  soap,  28 

Gummata  of  Fallopian  tubes,  309 
Gynecological     operations,     apparatus 
for,  454 
performance  of,  452 
personal  sterilizaiicjn  in,  455 
rubber  gloves  in,  457 
water  in,  459 
Gynecology,  delinition  of,  17 

Hands,  sterilization  of,  457 
Headache  in  endometritis,  203 

in  lacerated  cervix,  151 
Hematocele,  pelvic,  320 
Hematocolpos,  395 
Hematoma  between  suture  planes,  485 

of  broad  ligament,  314 

of  vulva,  48 

pelvic,  322 
Hematometra,  255 
Hematosalpinx,  278,  282,  283 

after  celiotomy,  492 

in  cervical  carcinoma,  188 

with  hematometra,  256 
Hemorrhage  after  rupture  of  tubal  preg- 
nancy, 313 

in  carcinoma  of  fundus  uteri,  221 

in  uterine  fibroid,  239 
Hemostatic  forceps.  Tail's,  462 
Hermaphroditism,  395 

hypospadia  in,  396 

ovarian,  330.     See  also  Ovarv. 
Hernia,  entero-vaginal,  90 
Hernial-sac  cyst,  44 
Hodge  pessarv,  132 
Hydrocele  of  canal  of  Nuck,  44 

ovarian,  342 
Hydrometra,  255 
Hydrosalpinx,  278,  281,  283 

with  hematometra,  256 
Hydrostatics  of  pelvic  contents,  96 
Hypertrophic  cervical   elongation,  176 
Hypospadia,  396 

Hysterectomy,  abdominal,  508,  514 
supra-vaginal     amputation,     509, 

combined    abdominal    and    vaginal, 
522 
advantages  of  author's  method, 

524 
Werder's,  523 
for  cervical  carcinoma,  191,  192 
complete,  514 
dangers,  514 

incisions    of  vaginal    fornix   in, 
514 


532 


INDEX. 


Hysterectomy  for  cervical    carcinoma, 
indications  for,  514 
remote  results,  193 
transplantation    of    cancer-cells 
during,  516 
for  fibroid,  515,  516 
for  inversion,  267 
for  prolapse,  III 
for  salpmgitis,  2q8 
for  uterine  fibroid,  251 
vaginal,  508,  51S 

removal     of    tubes    and    ovaries, 
521 

Incision  of  abdominal  wall,  479 
Infundibular     pregnancy,    311.      See 

also  i'uOal pregnancy. 
Inguinal  adenitis,  38 

hernia,  44 
Instillation-tube,  171 
Instruments  for  abdominal  operations, 
467 
sterilization  of,  45S 
Interstitial    pregnancy,  31 1.     See   also 

Tubal  pregnancy. 
Intestinal  tract,  evacuation  before  ope- 
ration, 463 
Intestines  and   omentum,  protection  of, 

during  operations,  481 
Intra-ligamentous    cyst,    marsupializa- 
tion, 507 
removal,  505 
Intra-ureteral  ligament,  429 
Intra-vesical  pressure,  429 
Inversion  of  uterus,  260 
Barnes'  bag  in,  265 
continuous  pressure  in,  266 
diagnosis  of,  263 
Emmet's  method  for,  265,  266 
hysterectomy  in,  267 
symptoms  and  sequelre  of,  262 
treatment  of,  264 
White's  repositor  for,  266 
with  uterine  polyp,  267 
with  vaginal  prolapse,  261 
Irrigation  after  curettement,  208 

of  abdominal  cavity,  water  for,  459 

Kelly's  instruments   for  examination 
of  bladder,  416 
method  for  locating  ureters  in  hys- 
terectomy, 514 
Kidney,  floating,  23 

movable,  23 
Knee-chest  position,  34 

for  rectal  examination,  35 
Kobelt's  tubes,  364 
Kolpokleisis,  412 
Kraurosis  vulvae,  46 


Labor  after  amputation  of  cervix,  163 

spurious,  317 
Laceration  of  cervix,  146 
concealed,  148 
incomplete,  148 

of  perineum,  60 
Latero-abdominal  position,  33 
Le  Fort's  operation  for  prolapse,  I  ID 
Leucorrhea,  151 

in  carcinoma  of  fundus  uteri,  221 

vicarious,  401 
Levator  ani,  55 
Ligament,  intra-ureteral,  429 

of  uterus,  93,  94 

utero-sacral,  29 
Ligation  of  circfilar  artery,  194 

of  uterine  arteries,  194 
Ligatures,  468,  469 
Lineae  albicantes,  21 
Link  ligature,  49S,  500 
Lupus   ulceration,  diagnosis   from  car- 
cinoma of  cervix,  1S6 
Lymphadenitis  in  lacerated  cervix,  152 
Lympliangitis   in   lacerated  cervix,  152 

Malignant  adenoma,  219 
Mammarv  changes  in  tubal  pregnancy, 

'318 

secretion,  periodical,  401 
Manometer,  429 
Marsupialization,  507 
Mass  suture,  483 
Massage,  pelvic,  295 
Meatus  internus,  position  of,  437 
Mechanism  of  perineum,  55 

of  uterine  support,  93 
Median   perineal  laceration,  repair  of, 

68 
Membranous  dysmenorrhea,  210 
Menopause,  398,  402 

due  to  salpingo-oophorectomy,  525 

in  chronic  oophoritis,  340 

in  ovarian  cysts,  376 

in  salpingitis,  290 

in  uterine  fibroid,  239 

operative,  502 
Menorrhagia   in   clironic   endometritis, 
202 
oophoritis,  340 
Menstruation  after  curettement,  2IO 

after  salpingo-oophorectomy,  525 

amount  of  flow  in,  397 

arrest  of,  by  operation,  502 

cessation  of,  398 

constituents  of  fluid  of,  397 

disorders  of,  397 

duration  of  flow,  397 

during  pregnancy,  244 

establishment  of,  397 


INDEX. 


533 


Menstruation,  frequency  of,  397 

in  anteflexion,  93 

in  chronic  endometritis,  202 

in  lacerated  cervix,  151 

in  retro-displacement,  13I 

in  tubal  pregnancy,  318 

neglect  during,  20 

precocious,  397 

regimen  during,  20 

scanty,  400 

suppression  of,  acute,  400 

systematic  effect  of,  20 

vicarious,  401 
Metastasis  in  carcinoma  of  cervix,  183 
Metritis  in  subinvolution,  213 

with  endometritis,  197 
Metrorrhagia   in  chronic  endometritis, 

202 
Micturition  after  celiotomy,  487 
Miliary  tubal  tuberculosis,  294 
Milk  as  a  diagnostic   agent   in   fistulse, 

406,  413 
Miscarriage  in  anteflexion,  121 
Morgagni,  cysts  of,  272,  365 
Mortality  after  celiotomy,  493 
Movable  kidney,  23 
Miiller,  ducts  of,  391 
Muscles  of  perineum,  56 
Myo-fibroma,  uterine,  227 
Myoma  of  Fallopian  tubes,  309 

uterine,  227 
Myomectomy,  abdominal,  252 

technique  of,  520,  523 
Myxoma,  ovarian,  386 
peritoneal,  374 

Nabothian  cysts,  150 
Needle  for  cervix,  154 

for  fistula,  410 

for  perineum,  63 
Needle-holder,  Emmet's,  63 

Reiner's,  469 
Neoplasms  of  vulva,  48,  51 
Normal  salt  solution,  460 
Nuck,  canal  of,  44 
Nurse's  duties  in  operating-room,  462 

Obturator,  35 

Oophoritis,   335.     See  also  Inflamma- 
tion of  Ovary. 
Operating-room,  453 

discipline  of,  462 

preparation  of,  454 

temperature  of,  454 
Operating-taV)le,  454 
Opium  after  celiotomy,  487 
Ostium  vaginse,  56 
Ovarian  abscess,  279 

adenomata,  530 


Ovarian  artery,  494 

ligation  of,  511,  516 
carcinomata,  388 
cyst,  17 

axial  rotation  in,  371 
dermoid,  503 
duration  of,  378 
examination  of,  379 
inflammation  of,  370,  378 
malignant  degeneration  of,  376 
marsupialization  of,  507 
necrosis  of,  373 
operation  for,  385 
pressure,  results  of,  375 
rapidity  of  growth,  377,  378 
removal  of,  503 
rupture  of,  373,  378 
causes  of,  379 
symptoms  of,  379 
treatment  of  pedicle,  505 
suppuration  of,  371 
symptoms  of,  374,  378 
tapping  of,  383,  503,  504 
thrombosis,  373 
torsion  of  pedicle  in,  371 

symptoms  of,  378 
treatment  of,  383,  385 
fibroid  uterus,  changes  in,  234 
fibromata,  386 
fibro-myomata,  284 
ligament,  bimanual   examination  of, 
27 
tumors  of,  390 
myomata,  386 
papillomata,  389 
sac,  344 
sarcomata,  387 
tuberculosis,  389 
Ovaritis,    335.     See    also    Ovary,   in- 
flammation of. 
Ovary,  accessory,  329 
after  menopause,  326 
anatomy  of,  326 
apoplexy  of,  342 
blood-vessels  of,  328 
chronic  inflammation,  treatment  of, 

340 
contents  of  glandular  cyst  of,  352 
corpus  luteum,  cyst  of,  348 
cystic,  338 

tumors  of,  345 
dermoid  cysts  of,  346,  355 
follicular  cysts  of,  346 

hemorrhage  in,  342 
glandular  cysts  of,  350,  368 
hernia  of,  330 

conception  in,  330 

dangers  in,  330 

menstruation  in,  330 


534 


INDEX. 


Ovary,  hernia  of,  ovulation  in,  330 
treatment  of,  331 
hydrocele  of,  342 
in  multiparae,  326 
in  new-born,  326 
inflammation  of,  acute,  335 
causes  of,  336 
symptoms  of,  336 
treatment  of,  337 
chronic,  337 

reflex  disturbance  in,  340 
from  salpingitis,  279 
hgaments  of,  327 
maintenance  of  position  of,  328 
multilocular  cyst  of,  350 
of  virgin,  326 
of  Wolffian  body,  329 
oophoritic  cysts  of,  346,  368 
oophoron,  329 
papillomatous  cyst  of,  358 
contents  of,  360 
in  ascites,  362 

peritoneal  involvement  in,  361 
rupture  of,  361 
paroophoritic  cysts  of,  358,  369 
ascites  in,  362,  376 
contents,  360 
dangers,  361 
wall  of,  358 
paroophoron,  329 
pedicle  of  glandular  cyst  of,  354 
prolapse  of,  331 
causes,  331 

diagnosis  from  retroflexion,  333 
pessary  in,  335 
reflex  symptoms,  333 
secondary  changes,  332 
treatment  of,  333,  335 
tuberculosis  of,  389 
veins  of,  328 
Oxyuris,  39 

Pain  after  celiotomy,  487,  489 
in  carcinoma  of  fundus  uteri,  221 
in  cervical  carcinoma,  189 
in  salpingitis,  28S 
in  uterine  fibroid,  241 

Palpation  of  abdomen,  22 

Papilloma  of  ovary,  389 
of  vulva,  48 

Papillomatous  ovarian  cysts,  358 

Parenchyma  body,  355 

Paroophoritic  cysts,  258,  369 

Paroophoron,  329 

Parovarium,  54,  364 
cysts  of,  364,  366,  369 
Gartner's  duct,  364 
Kobelt's  tubes,  364 
papillomatous  cysts  of,  366 


Parturition  as  cause  of  retro-displace- 
ments, 128 
results  of  injuries  during,  18 
Patient,  preparation    of,  for  operation, 

463 
Pedicle-needle,  468 
Pelvic  abscess,  299 

after  rupture  of  tubal  pregnancy, 

313 
celiotomy  for,  301 
vaginal  evacuation  of,  300 
contents,  hydrostatics  of,  96 
massage,  295 

in  amenorrhea,  400 
structures,  rectal  examination  of,  30 
Pelvis,  local  washing  of,  481 

suppuration  of  cellular  tissue  in,  299 
Percussion  of  abdomen,  24 

in  ascites,  24 
Perineal    laceration    involving    one    or 
both  vaginal  sulci,  73,  77,  78 
recto-vaginal  septum,   71,  72 
loss  of  support  in,  67,  73,  128 
repair,  68 

sphincter-tear,  suture-introduction, 
66,  69,  70 
removal  of  sutures,  71 
subcutaneous,  77,  83 
needle,  Emmet's,  63 
needle-carrier,  64 
scissors,  Emmet's,  62 
Perineorrhaphy,  60,  61,  78 
after-treatment  of,  64 
intermediate,  61 
passage  of  sutures  in,  65,  66 
primary,  60 
secondary,  62 
Perineum,  anatomy  and  mechanism  of, 

55 
characteristics    after    sulci-tear,    76, 

77. 
of  uninjured,  75 
fascise  of,  56 
injuries  to,  60 
lacerations,  classification  of,  78 

Emmet's  operation  for,  78 
ligaments,  56 
median  laceration  of,  65 

involving  sphincter,  66 
muscles,  56 
Peri-oophoritis,     in      inflammation    of 

ovary,  335 
Peritoneum,   action   of  antiseptics    on, 

449 
causes  of  infection  of,  477 
cleansing  before  operation,  482 
infection  in  minor  gynecology,  450 
toilet  of,  4S2 
Peritonitis  after  celiotomy,  492 


INDEX. 


535 


Pessary,  contraindications  to  use,  139 
Hodge,  132 
in  anteflexion,  121 
in  retro-displacement,    131,  144 
Smith,  131 
stem,  121 
Thomas,  132 
vaginal,  131,  136,  138 
Pfliiger,  tubes  of,  350 
Phantom  tumor,  382 
Polypi  of  cervix,  176,  180 
tubal  pregnancy  and,  310 
urethral,  427 
uterine,  231,  253 
with  endometritis,  201 
Position,  dorsal,  33 
genu-pectoral,  ^Z'  34 
knee-chest,  33,  35 
latero-abdominal,  33 
of  uterus,  92 
Sims',  33,  34 
Trendelenburg,  454,  501 
Post-climacteric  endometritis,  211 
Pregnancy  after  amputation  of  cervix, 
163 
after  celiotomy,  385 
after  curettement,  210 
as  cause  of  prolapse,  106 
extra-uterine,  310.     See  also  Tubal 

pregnancy. 
in  anteflexion,  121 
influence  on  anteflexion,  1 21 
tubal,  310.       See  also    Tubal  preg- 
nancy. 
with  uterine  fibroid,  244,  252 
Probe,  vesical,  418 

Prolapse  of  ovary,  331.   See  also  Ovary. 
of  urethra,  424 
of  uterus,  73,  99 

amputation  of  cervix  in,  iii 
causes,  100,  106 
colpeurynter  in,  116 
cystocele  and  rectocele  in,  105 
diagnosis,  107 
hyste"rectomy  for,  ill 
LeFort's  operation,  1 10 
pessaries,  1 15 
sequelae,  108 
structural  changes,  104 
subjective  symptoms,  106 
treatment,  108 
ventro-fixation  in,  no 
of  vagina,  73 
Pruritus  vulvae,  44 

diabetes  as  cause,  45 
etiology,  44,  45 

excision  of  mucous  membrane,  46 
treatment,  45 
Pseudo-hermaphroditism,  395 


Pseudo-mucin,  352 

Pulse  after  celiotomy,  490 

Purgation  after  celiotomy,  488 

Pus,  sterile,  280,  478 

Pyelitis,  result  of  cystitis,  430 

Pyometra,  255 

Pyosalpinx,  256,  278,  280,  283 

cholesterin  deposits  in,  281 

conversion  into  hydrosalpinx,  281 

micro-organisms  in,  280 

reinfection,  281 

rupture  of,  285 

spontaneous  evacuation,  280 

sterile  pus,  280 

Rectal  examination  of  pelvic  struct- 
ures, 30 
of  uterus,  29 
specula,  35 

tube  in  abdominal  distention,  489 
Rectocele,  75,  85,  105 
Recto-vaginal  fistulse,  413 
septum,  laceration  of,  71 
Rectum  examination,  35 

knee-chest  position  for,  35 
Recurrent  fibroid,  225 
metastasis  in,  225 
origin  of,  225 
uterine  inversion  in,  225 
Reflux  tube  in  uterine  irrigation,  208 
Reiner's  needle-holder,  469 
Replacement  of  uterus,  133 
Reposition,  bimanual,  133 

instrumental,  134 
Repositor,  White's,  266 
Retractor  for  vagina,  51S 
Retro-displacement,    Alexander's  ope- 
ration, 140 
diagnosis  of,  131 
menstruation  in,  131 
operation  for,  140 
pessaries  in,  131 
pregnancy  and, 128 
results  of,  129 
symptoms  of,  130 
treatment  of,  131,  143 
ventro-fixation  for,  131 
Retroflexion  of  uterus,  125 

causes  of,  127 
Retroversion  of  uterus,  125 
causes  of,  127 
degrees  of,  126 
Reverdin's  method  for  sterilization  of 

catgut,  470 
Rheumatism  cause  of  ovarian  disease, 

336 
Robb's  formulae  for  celloidin,  471 
Room  for  gynecological  operations,  453 
Round  ligament,  ligation  of,  511 


536 


INDEX. 


Round-ligament  cysts,  44 
Rubber  dam,  472 
gloves,  457 

Salpingitis,  272,  283 

abdominal  ostium,  closure  of,  276 

acute,  273,  284 

adhesions  due  to,  275,  276 

after  endometritis,  284,  295 

catarrhal,  274 

causes  of,  272,  275,  283 

celiotomy  for,  292,  295,  296 

chronic,  275 
catarrhal,  275 
interstitial,  276 

cystic  distention  in,  278 

clangers  of,  285,  287 

diagnosis  of,  291 

fistula  in,  2S6 

hematosalpinx  with,  278 

hydrosalpinx  with,  278 

hypertrophy  in,  277 

hysterectomy  for,  298 

ovarian  abscess  and,  279 

ovaritis  and,  279 

pelvic  abscess  in,  293 
massage  in,  295 

pyosalpinx,  278 

salpingo-oophorectomy  for,  298 

septic,  273,  284 

symptoms  of,  287 

treatment  of,  292,  294 

tub;il  pregnancy  from,  310 

with  tubal  abscess,  275,  279 
Salpingo-oophorectomy,  496 

adhesions  after,  501 

for  chronic  ovaritis,  340 

for  salpingitis,  298 

for  uterine  fibroid,  249 

link-ligature  in,  498 

menopause  due  to,  525 

menstruation  after,  525 

secondary  effects  of,  525 

sexual  emotion  after,  526 

Tait  knot,  498 
Sarcoma  of  ovary,  387 

of  uterus,  17,  223 

age  of  occurrence,  226 
duration  of,  226 
symptoms  of,  224 
treatment  of,  226 

urethral,  428 
Scissors,  Emmet's  perineal,  62 
Senile  endometritis,  211 
Septic  infection  of  genital  tract,  19 

foci,  dangers  of,  39 
Shock  after  celiotomy,  490 
Shot-compressor,  64 
Silk,  468 


Sims'  curette,  207 
depressor,  31 
position,  2,^ 

topographical  changes  in,  34 
speculum,  31 

as  anal  retractor,  35 
vagmal  dilator,  408 
Skene's  endoscope,  425 
glands,  419 

inflammation  of,  422 
installation  tube,  171 
reflux  catheter,  422 
Smith's  pessary,  132 
Sound,  urethral,  423 
uterine,  36 

asepsis  in  use  in,  37 

diagnosis  between   inversion   and 

polyp  by  use  of,  264 
precautions  in  use  of,  37 
Speculum,  rectal,  35 
vaginal,  30 

bivalve,  Goodell's,  31 
duck-bill,  Sims',  31 
introduction,  31,  35 

uses,   30,   32,    T,T, 

vesical,  417 
Spencer  Wells'  forceps,  466 
Sphincter  ani,  56 

atrophy  after  laceration  of,  67 
dimple  over  ends  of,  68 
laceration,  repair  of,  67 

vaginae,  57 
Split  cervix,  175 
Sponge-holder,  63 
Sponges  in  abdominal  operations,  466 

sterilization  of,  460 
Sprague's  sterilizer,  458 
Spurious  labor,  317 
Squamous-cell     carcinoma    of    cervix, 

179 
Stem-pessary  in  anteflexion,  1 21 
Sterility  as  result  of  gonorrhea,  19 

in  anteflexion,  120 

in  chronic  endometritis,  204 

in  lacerated  cervix,  152 

in  salpingitis,  290 
Sterilization,  discontinuous,  458 

fractional,  458 

of  dressings,  458 

of  hands,  457 

of  instruments,  458 

of  sponges,  460 

of  tables,  455 

of  water,  459 

personal,  for  operations,  455 
Sterilizer,  Arnold's,  458 

Sprague's,  458 
Stoltz's  operation  for  cystocele,  89 
Stricture,  urethra,  423 


INDEX. 


537 


Subinvolution  as  cause  of  ovarian  pro- 
lapse, 332 
of  uterus,  213 

endometritis  in,  213 
metritis  in,  213 

symptoms  and  treatment  of,  214 
of  vagina,  90 
Superinvolution  of  uterus,  215 

amenorrhea  in,  215 
Suppressio  mensium,  398 
Supra-vaginal  cervix,  elongation  of,  I02 
Sutures,  468,  469 

Syphilis  acquired  during  examination, 
28 
elephantiasis  in,  49 
primary  sore  on   finger  of  physician, 
28 
Syphilitic    ulceration,   diagnosis    from 

carcinoma  of  cervix,  186 
Syringe    for    cleansing    drainage-tube, 
473 

Table  for  operating,  454 

sterilization  of,  455 
Tait  knot,  498,  500 
Tait's  hemostatic  forceps,  466 
Tapping  of  ovarian  cyst,  383,  503,  504 

dangers  of,  384 
Temperature  after  celiotomy,  490 
Tenacula,  29,  62 
Teratoma,  357 
Thomas's  pessary,  132 
Through-and-through  suture,  483 
Tissue-forceps,  63 
Trachelorrhaphy,  154 
contraindications  to,  285 
curetting  in,  158 
preparation  for,  158 
scissors  for,  1 55 
Transplantation  of  cancer-cells  during 

hysterectomy,  516 
Trendelenburg  position,  454,  501 
Trigone,  428 

mucous  membrane  of,  429 
Trocar,  468 

Tubal  changes  in  fibroids,  234 
pregnancy,  310 

abdominal  enlargement  in,  318 
abortion,  312,  314 
amenorrhea  in,  322 
ballottement  in,  319 
causes  of,  310 
classification  of,  311 
curettage  for  diagnosis  in,  31 1 
diagnosis  of,  321 
P"al]o]5ian  tube,  changes  in,  311 
fetal  movements  in,  319 
heart-sounds  in,  319 
hematoma  in,  313 


Tubal   pregnancy,  hemorrhage  in,  313 
mammary  changes  in,  318 
menstruation  in,  318 
pain  in,  318,  320 
placental  hemorrhage  during  celi- 
otomy for,  324 
polypi  as  cause  of,  310 
rupture  in,  312,  313,  320,  323 
secondary  rupture,  313 
skin-changes  in,  317 
spurious  labor  in,  317 
symptoms  of,  317 
termination  of,  312,  324 
treatment  of,  323 
tubal  changes  in,  311 
uterine  changes  in,  312,  316 
vaginal  changes  in,  31 S 
varieties  of,  31 1 
Tuberculosis  of  cervix,  178 
of  Fallopian  tubes,  302 
chronic  diffuse,  305 

fibroid,  305 
diagnosis  of,  307 
infection  of,  306 
miliary,  304 
primary,  305 
prognosis  in,  307 
secondary,  306 
symptoms,  306 
treatment  of,  308 
unsuspected,  304 
of  ovary,  389 
of  uterus,  257 
Tubo-ovarian  abscess,  279,  283 

pregnancy,    310.     See    also    Tubal 
p7-egnancy. 

Ureter,  bimanual  examination  of,  27 

carcinoma  of,  183 

introduction  of  bougies  in  hysterec- 
tomy, 514 

relations  of,  437,  512,  517 
to  uterine  artery,  496 

vesical  orifice  of,  429 
Ureteritis,  result  of  cystitis  in,  430 
Urethra,  anatomy  of,  419 

cancer  of,  428 

caruncle  of,  426 

course  of,  437 

cysts  of,  427 

prolapse  of,  424 

sarcoma  of,  428 
Urethral  polyp,  427 

sound,  423 

stricture,  423 
Urethritis,  420,  441 
Urinary  excretion  after  celiotomy,  428 
Uterine  appendages,  removal  of,  496 

artery,  495 


538 


INDEX. 


Uterine    arterv,  ligation  of,    194,  511, 

516' 

relations  to  ureter,  89 
cavity,  length  of,  36 
cornua,  bimanual  examination  of,  27 
fibroid,  227 
fibro-myoma,  227 
forceps,  136 

inversion  in  recurrent  fibroid,  225 
involvement    in   cervical   carcinoma, 

183 
ligaments,  action  of,  94 

structure  of,  94 
myofibroma,  227 
myoma,  227 
polyp,  231 

diagnosis  from   carcinoma  of  cer- 
vix, 186 

with  inversion,  267 
retro-displacements,    parturition      as 

cause,  128 
retroflection,  causes  of,  127 
sound, 36 

abortion  by  use  of,  37 

asepsis  in  use  of,  37 

dangers  of,  37 

in    diagnosis    between     inversion 
and  uterine  polyp,  264 

precautions  in  use,  37 
Utero-sacral  ligaments,  29,  117 
Uterus,  absence  of,  392 
anteflexion,  117 

causes  of  normal,  1 17 

classification  of,  1 18 

menstruation  in,  120 

miscarriage  in,  121 

pathological,  118 

pessary  in,  121 

pregnancy  in,  121 

sterility  in,  120 

symptoms  of,  1 20 

treatment  of,  121 
axis  of,  93 
bicornis  duplex,  392 

unicollis,  393 
bimanual  reposition,  133 
carcinoma  of,  216 

age  of  occurience,  21S 

bimanual  examination  of,  222 

curette,  222 

leucorrhea,  221 

metastasis,  221,  222 

operation  for,  222,  223 

pain,  221 

symptoms,  220 
cordiformis,  393 
development,  391 
didelphys,   392 
fibroid  tumors  of,  227 


Uterus,    fibroid    tumors    of,   intraliga- 
mentous, 232 
submucous,  231 
subperitoneal,  230 
fibro-sarcoma  of,  225 
instrumental  reposition,  134 
inversion  of,  260 

diagnosis  from  uterine  polyp,  264 

reposition  in,  264 

White's  repositor  for,  265 
irrigation  after  curettement,  208 
ligaments  of,  93 
mechanism  of  supjion,  93,  94 
perforation  of,  by  curette,  208 
position,  92,  117 
prolapse  of,  99 

amputation  of  cervix  in.  III 

causes  of,  95,  96,  loo,  106 

colpeurynter  in,  1 16 

cystocele  and  rectocele  in,  105 

diagnosis  of,  107 

Emmet's  operation  for,  109 

hysterectomy  for,  i  r  i 

LeFort's  operation,  no 

pessaries  in,  115 

pregnancy  as  cause  of,  io6 
sequelse  of,  108 

Sims'  operation  for,  113 

structural  changes  in,  104 

symptoms,  106 

treatment,  loS 

ventrofixation  for,  no 
rectal  examination  of,  29 
relations  of,  117 

to  bladder,  92 
removal,    506.     See    also    Hysterec- 

tofny. 
replacement,  133,  134 

contraindications  to,  285 
retention  in  position,  140 
retro-displacement,   congenital,    127, 

144 
retroflexion  of,  125 
retroversion  of,  125 

causes,  127 

degrees,  126 
sarcoma  of,  223 

age  of  occurrence,  226 

duration  of  life,  226 

symptoms,  223,  224 

treatment,  223 

varieties,  223 
septus,  393 
Skene's  glands,  419 
stitching  to  abdominal  wall,  140 
subinvolution  of,  213 
superinvolution   after  amputation    of 

cervix,  215 
supra-vaginal  amputation,  509,  512 


INDEX. 


539 


Uterus,  supra-vaginal  amputation,  clos- 
ure of  cervical  canal  in,  513 
sterilization  of  cervical  canal  in, 

S13 
tuberculosis  of,  257 
unicornis,  392 
vascular  supply  of,  429 

Vagina,  absence  of,  394 

angle  of,  58 

anterior  wall,  length,  59 

atresia,  19 

carcinoma  of,  54 

cysts  of,  53 

development  of,  391 

dilator  for,  Sims',  408 

fibroid  tumors  of,  54 

furrows  of,  59 

incision  of,  in  hysterectomy,  514 

inflammation  of,  51 

long  axis  of,  58 

malformations  of,  393 

normal  condition  of,  94 

ostium  of,  56 

posterior  wall,  length  of,  59 

preparation  of,  for  operation,  464 

prolapse  of,  73 

sarcoma  of,  54 

shape  of,  59 

subinvolution  of,  90 

sulci  of,  59 

unilateral,  394 
Vaginal  arteries,  496 

cervix,  elongation,  102,  176 

drainage,  472,  479 

examination,  25 
cleansing  for,  2S 
contraindications  to,  30 
hematocolpos,  395 
hysterectomy,  518 

removal  of  tubes  and  ovaries,  521 
pessaries,  131,  136,  138 
retractor,  518 
speculum,  30 

bivalve,  Goodell's,  31 
duck-bill,  Sims',  31 
uses,  30,  32,  33 
sulci,  laceration  of,  73 
tumor,  53 

treatment,  54 
wall-depressor,  31,  t^t^,  34 
Vaginitis,  51 
adhesive,  53 
dangers  of,  52 
emphysematous,  51 
epidemics  of,  41 
etiology,  51 
gonorrheal,  445 
granular,  51 


Vaginitis  in  children,  51 
in  exanthemata,  51 
senile,  51 
simple,  51 
symptoms,  52 
treatment,  52,  53 
Ventral  hernia,  484 
Ventro-fixation,  140,  141 
in  uterine  prolapse,  1 10 
Ventro-suspension,  140,  141 

incision  for,  479 
Vermiform  appendix,  23 
Vesical  applicator,  418 
calculus,  438 

in  vesico-vaginal  fistula,  408 
probe,  418 
speculum,  416 
triangle,  428 

mucous  membrane  of,  429 
nerves  of,  429 
Vesico-urethral  fissure,  424 
Vesico-uterine  fistula,  413 
Vesico-vaginal  fistula,  404 
and  calculus,  408 
kolpokleisis  in,  412 
operation  for,  409 
treatment,  407 
Vicarious  menstruation,  401 
Vomiting  after  celiotomy,  489 
Vulva,  elephantiasis  of,  49 
gonorrhea  of,  446 
hematoma  of,  48 
neoplasms  of,  48,  49 
papilloma  of,  48 
pruritus  of,  44 
etiology,  44,  45 

excision  of  mucous  membranes,  46 
treatment,  45 
varicose  tumors  of,  48 
Vulvitis,  1% 

causes  of,  38,  39 
j  epidemics  of,  39 
'       follicular,  38 

gonorrhea  as  cause  of,  38 
in  children,  39 
late  manifestations  of,  39,  40 
medico-legal  examination  in,  39 
secondary,  38,  39 
symptoms  of,  38 
treatment  of,  39 
•Vulvo-vaginal  glands,  cysts  of,  42 
inflammation  of,  40,  41 

Water  after  celiotomy,  486 

in  gynecological  operations,  459 
sterilization  of,  459 

Werder's  combined   hysterectomy,  523 

White's  repositor,  266 

Wolffian  canal,  54 


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Edited  by  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to 
the  Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  Amer- 
ican Academy  of  Medicine.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges.     Price  $1.00  net;  with  thumb  index,  $1.25  net. 

The  American  Year- Book  qf  Medicine  and  Surgery. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-ljooks  of  the  leading  American  and  Foreign  authors  and  investi- 
gators. Arranged  with  critical  editorial  comments,  by  eminent  Amer- 
ican specialists,  under  the  editorial  charge  of  Gkorge  M.  Gould,  M.  D. 
Year-Book  of  1902  in  twovohmies — Vol.  I.  including  General  Medicine; 
Vol.  II.,  General  Suri^ery.  Per  volume :  Cloth,  $3.00  net;  Half  Mo- 
rocco, $2)-1S   ^^^-     Sold  by  Subscription. 


MEDICAL  PUBLICATIONS 


Abbott  on  Transmissible  Diseases,    second  Edition.  Revised. 

The  Hygiene  of  Transmissible  Diseases :  their  Causation,  Modes  of 
Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  351  pages,  with  numerous  illustrations.     Cloth,  $2.50  net. 

Anders*  Practice  qf  Medicine.       Fifih  Revised  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo  volume  of  1297  pages,  fully  illustrated.  Cloth,  I5.50  net; 
Sheep  or  Half  Morocco,  $6.50  net. 

Bastin's  Botany. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  M.  A.,  late 
Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.     Octavo,  536  pages,  with  87  plates.     Cloth,  ^2.00  net. 

Beck  on  Fractures. 

Fractures.  By  Carl  Beck,  M.  D.,  Professor  of  Surgery,  New  York 
Post-graduate  Medical  School  and  Hospital.  With  an  appendix  on  the 
Practical  Use  of  the  Rontgen  Rays.  335  pages,  170  illustrations. 
Cloth,  $3.50  net. 

Beck's  Surgical  Asepsis. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.  D.,  Professor  of 
Surgery,  New  York  Post-graduate  Medical  School  and  Hospital.  306 
pages;  65  text-illustrations  and   12  full-page  plates.     Cloth,  ^1.25  net. 

Bergey's  Principles  of  Hyg(iene. 

The  Principles  of  Hygiene  :  A  Practical  Manual  for  Students,  Physi- 
cians, and  Health  Officers.  By  D.  H.  Bergey,  A.  M.,  M.  D.,  First 
Assistant,  Laboratory  of  Hygiene,  University  of  Pennsylvania.  Hand- 
some octavo  volume  of  495  pages,  illustrated.     Cloth,  ^3.00  net. 

Boisliniere's    Obstetric  Accidents,   Emergencies,  and 
Operations. 

Obstetric  Accidents,  Emergencies,  and  Operations.  By  L.  Ch.  Bois- 
LiNiERE,  M.  D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis  Medical 
College.     381  pages,  handsomely  illustrated.     Cloth,  $2.00  net. 

Bohm,  Davidoff,  and  Huber's  Histology. 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Technic. 
By  Dr.  A.  A.  Bohm  and  Dr.  M.  von  Davidoff,  of  Munich,  and 
G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of 
Histological  Laboratoiy,  University  of  Michigan.  Handsome  octavo 
of  503  pages,  with  351  beautiful  original  illustrations.     Cloth,  $3.50  net. 


OF  W.  B,  SAUNDERS  6-  CO. 


Brower  o/i?  Bannister's  Manual  of  Insanity. 

A  Practical  Manual  of  Insanity.  For  the  Student  and  General  Practi- 
tioner. By  Daniel  R.  Brower,  A.  M.,  M.  D.,  LL.D.,  Professor  of 
Nervous  and  Mental  Diseases  in  Rush  Medical  College,  in  Affiliation 
with  the  University  of  Chicago,  and  in  the  Post-Graduate  Medical 
School,  Chicago;  and  Henry  M.  Bannister,  A.  M.,  M.  D.,  formerly 
Senior  Assistant  Physician,  Illinois  Eastern  Hospital  for  the  Insane. 
Handsome  octavo,  426  pages,  with  13  full-page  inserts.    Cloth,  $3.00  net. 

Butler's  Materia  Medic  a.  Therapeutics,  and  Pharma- 
cology.     Fourth  Edition,  Revised  and  Enlarged. 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharmacology. 
By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  of  Materia  Medica  and 
of  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
Octavo,  896  pages,  illustrated.  Cloth,  ^4.00  net;  Sheep  or  Half  Mo- 
rocco, ^5.00  net. 

Chapin  on  Insanity. 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.  D.,  LL.  D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  Honorary 
Member  of  the  Medico-Psychological  Society  of  Great  Britain,  of  the 
Society  of  Mental  Medicine  of  Belgium,  etc.  i2mo,  234  pages,  illus- 
trated.    Cloth,  ^1.25  net. 

Chapman's   Medical    Jurisprudence  and  Toxicology. 

Second  Edition,  Revised. 

Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence, 
Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55  illus- 
trations and  3  full-page  plates  in  colors.     Cloth,  $1.50  net. 

Chtnrch  an'd  Peterson's  Nervous  and  Mental  Diseases. 

Third  E^dltion,  Revised  and  Enl£u-ged. 

Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  and  Head  of  the  Neurological 
Department,  Northwestern  University  Medical  School,  Chicago ;  and 
Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York.  Handsome  octavo 
volume  of  875  pages,  profusely  illustrated.  Cloth,  ^5.00  net;  Sheep  or 
Half  Morocco,  $6.00  net. 

Clarkson's  Histology. 

A  Text-Book  of  Histology,  Descriptive  and  Practical.  By  Arthur 
Clarkson,  M.  B.,  CM.  Edin.,  formerly  Demonstrator  of  Physiology 
in  the  Owen's  College,  Manchester;  late  Demonstrator  of  Physiology 
in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages;  22  engravings 
and  174  beautifully  colored  original  illustrations.     Cloth,  ^4.00  net. 

Corwin's  Physical  Diagnosis.    Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur  M. 
Corwin,  a.  M.,  M.  D.,  late  Instructor  in  Physical  Diagnosis  in  Rush 
Medical   College,   Chicago.     219  pages,  illustrated.     Cloth,  ^$1.25  net. 


MEDICAL  PUBLICATIONS 


Crothers'  Morphinism  and  Narcomania. 

Morphinism  and  Narcomania  from  Opium,  Cocain,  Ether,  Chloral, 
Chloroform,  and  other  Narcotic  Drugs ;  also  the  Etiology,  Treatment, 
and  Medicolegal  Relations.  By  T.  D.  Crothers,  M.  D.,  Superin- 
tendent of  AValnut  Lodge  Hospital,  Hartford,  Conn.  ;  Professor  of 
Mental  and  Nervous  Diseases,  New  York  School  of  Clinical  Medicine, 
etc.     Handsome  i2mo  of  351  pages.     Cloth,  ^2.00  net. 

DaC0Sta*S    Surgery.      Third  Edition.  Revised. 

Modern  Surgery,  General  and  Operative.  By  John  Chalmers  Da 
Costa,  M.  D.  ,  Professor  of  Principles  of  Surgery  and  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia;  Surgeon  to  the  Philadelphia 
Hospital,  etc.  Handsome  octavo  volume  of  11 17  pages,  profusely 
illustrated.     Cloth,  $5.00  net;   Sheep  or  Half  Morocco,  ^6.00  net. 

Enlarged  by  over  200  Pages,  with  more  than  100  New  Illustrations. 

Davis's  Obstetric  Nursing'. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics,  Jefferson  Medical  College  and  Phila- 
delphia Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia  Hos- 
pital.     i2mo,  400  pages,  illustrated.      Crushed  Buckram,  $1.75  net. 

DeSchweinitz  on  Diseases  qf  the   Eye.      Fourth  Edition. 

Entirely  Reset ;  Thoroughly  Revised  and  Enlao-ged. 

Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G. 
E.  DE  ScHWEiNiTZ,  M.  D.,  Profcssor  of  Ophthalmology,  Jefferson  Medi- 
cal College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  750 
pages ;  300  fine  illustrations  and  6  full-page  chromo-lithographic  plates. 
Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 

Dorland's  Dictionaries. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictionary  on  page  3.] 

Dorland's    Obstetrics.       second  Edition.  Revised  and  Greatly  Enlarged. 

Modern  Obstetrics.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Associate  in 
Gynecology,  Philadelphia  Polyclinic.  Octavo  volume  of  797  pages, 
with  201  illustrations.     Cloth,  ^4.00  net. 

Eichhorst's  Practice  cf   Medicine. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  Hermann  Eich- 
horst,  Professor  of  Special  Pathology  and  Therapeutics  and  Director 
of  the  Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Phila- 
delphia Polyclinic.  Two  octavo  volumes  of  600  pages  each,  over  150 
illustrations.  Prices  per  sgt :  Cloth,  ^6.00  net ;  Sheep  or  Half  Morocco, 
^7.50  net. 


OF  W.   B.  SAUNDERS  6-   CO. 


Eyre's  Bacteriologic  Technique. 

Bacteriologic  1  echnique.  A  Laboratory  Guide  for  the  Medical,  Dental, 
and  Technical  Student.  By  J.  W.  H.  Eyre,  M.  D.,  F.  R.  S.,  Edin., 
Lecturer  on  Bacteriology  and  Joint  Lecturer  on  Practical  Public  Health, 
Charing  Cross  Hospital  Medical  School ;  Bacteriologist  to  Charing 
Cross  and  to  St.  Mary's  Hospital  for  Sick  Children,  Plaistow.  Hand- 
some octavo,  350  pages,  with  150  illustrations.     Cloth,  $0.00  net. 

Friedrich  and  Curtis  on  the  Nose,  Throat,  and  Ear. 

Rhinology,  Laryngology,  and  Otology,  and  Their  Significance  in  Gen- 
eral Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H. 
HoLBROOK  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose 
and  Throat  Hospital.     Octavo,  348  pages.     Cloth,  $2.50  net. 

Frothingham's  Guide  for  the  Bacteriologist. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Frothingham, 
M.  D.  v.,  Assistant  in  Bacteriology  and  A^eterinary  Science,  Sheffield 
Scientific  School,  Yale  University.      Illustrated.      Cloth,  75   cts.  net. 

Galbraith  on  the  Four  Epochs  qf  Woman's  Life. 

The  Four  Epochs  of  Woman's  Life  :  A  Study  in  Hygiene.  By  Anna 
M.  Galbraith,  M.  D.,  Author  of  "Hygiene  and  Physical  Culture 
for  Women";  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
With  an  Litroductory  Note  by  John  H.  Musser,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania.  121110  volume  of  200 
pages.     Cloth,  ^1.25  net. 

Garrigues*  Diseases  qf  Women.    Third  Edition.  Revised. 

Diseases  of  Women.  By  Henry  J.  Garrigues,  A.M.,  M.  D.,  Gyne- 
cologist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New 
York  City.  Octavo,  756  pages,  with  367  engravings  and  colored  plates. 
Cloth,  ^4.50  net;  Sheep  or  Half  Morocco,  ^5.50  net. 

Gorham's  Bacteriology. 

A  Laboratory  Course  in  Bacteriology.  By  F.  P.  Gorham,  M.  A., 
Assistant  Professor  in  Biology,  Brown  University.  i2nio  volume  of 
192  pages,  97  illustrations.      Cloth,  $1.25   net. 

Gould  and  Pyle*s  Curiosities  qf  Medicine. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould,  M.D., 
and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of  rare  and 
extraordinary  cases  and  of  the  most  striking  instances  of  abnormality  in 
all  branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive 
research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages;  295  engravings  and  12  full-page  plates.  Popular 
Edition.      Cloth,  ^3.00  net;  Sheep  or  Half  Morocco,  $4.00  net. 

Gradle  on  the  Nose,  Throat,  and  Ear. 

Diseases  of  the  Nose,  Throat,  and  Ear.  By  Henry  Gradle,  M.  D., 
Professor  of  Ophthalmology  and  Otology,  Northwestern  University 
Medical  School,  Chicago.  Octavo,  547  pages,  illustrated,  including 
2  full-page  colored  plates.     Cloth,  IS3.50  net. 


8  MEDICAL  PUBLICATIONS 

Grafstrom's  Mechano-Therapy. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician,  City  Hos- 
pital, Blackwell's  Island,  N.  Y.    i2mo,  139  pages,  illustrated.    $1.00  net. 

Grant's  Surgical  Diseases  of  Face,  Mouth,  and  Jaws. 

For  Dental  Students. 

A  Text-Book  of  Surgical  Pathology  and  Surgical  Diseases  of  the  Face, 
Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace  Grant, 
A.  M.,  M.  D.,  Professor  of  Surgical  Pathology  and  Oral  Surgery,  Louis- 
ville College  of  Dentistry ;  Professor  of  Surgery  and  Clinical  Surgery, 
Hospital  College  of  Medicine,  Louisville.  Octavo  volume  of  215 
pages,  with  60  illustrations.     Cloth,  $0.00  net. 

Griffith    on    the    Baby.       second  sedition.  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Pennsylvania;  Phy- 
sician to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages; 
67  illustrations  and  5  plates.     Cloth,  ^1.50  net. 

Griffith's  Weight  Chart. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 
25  charts  in  each  pad.     Per  pad,   50  cts.  net. 

Haynes'  Anatomy. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.  D.,  Professor  of 
Practical  Anatomy  in  Cornell  University  Medical  College.  680  pages ; 
42  diagrams  and  134  full-page  half-tone  illustrations  from  original  photo- 
graphs of  the  author's  dissections.     Cloth,  $2.50  net. 

Heisler*S    Embryology.       second  Edition,  Revised, 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor 
of  Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volume 
of  405  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

HirsfS    Obstetrics.       Third  Edition,  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D.,  Professor 
of  Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume 
of  873  pages  ;  704  illustrations,  ^d  of  them  in  coloi-s.  Cloth,  ^5.00  net ; 
Sheep  or  Half  Morocco,  $6.00  net. 

Hyde  and  Montgomery  on  Syphilis  and  the  Venereal 

Diseases.       second  Edition,  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D., 
Professor  of  Skin,  Genito-Urinary,  and  Venereal  Diseases,  and  Frank 
H.  Montgomery,  M.  D.,  Associate  Professor  of  Skin,  Genito-Urinary, 
and  Venereal  Diseases  in  Rush  Medical  College,  Chicago,  111.  Octavo, 
594  pages,  profusely  illustrated.     Cloth,  $4.00  net. 


OF  W.  B.    SAUNDERS  ^  CO. 


^e  International  Text-Book  of  Surgery,     in  Two  volumes. 

Second  Edition,  Thoroughly  Revised  and  Greatly  Enlarged. 

By  American  and  British  Authors.  Edited  by  J.  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medi- 
cal School,  Boston ;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer 
on  Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex 
Hospital-  Medical  School,  London,  Eng.  Vol.  L  General  Surgery.— 
Handsome  octavo,  947  pages,  with  458  beautiful  illustrations  and  9 
lithographic  plates.  Vol.  IL  Special  or  Regional  Surgery. — Handsome 
octavo,  1072  pages,  471  text  illustrations,  and  8  lithographic  plates. 
Per  volume:   Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  ^6.00  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The  clini- 
cian and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satis- 
faction to  the  editors  as  it  is  a  gratification  to  the   conscientious  reader." — Annals  of  Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has  very 
many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors 
is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor  of  each 
;vriter  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the  technique 
01  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up  to  date  in 
a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional  parts  of  the 
body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which  the  reader 
may  not  learn  something  new." — Medical  Record,  New  York. 

Jackson's  Diseases  qf  the  Eye. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine.  i2mo  volume  of  535  pages,  with 
178  illustrations,  mostly  from  drawings  by  the  author.    Cloth,  ^2.50  net. 

Jelliffe  and  Diekman*s  Chemistry. 

A  Text- Book  of  Chemistry.  By  Smith  Ely  Jelliffe,  M.  D.,  Ph.  D., 
Professor  of  Pharmacology,  College  of  Pharmacy,  New  York ;  and 
George  C.  Diekman,  Ph.  G.,  M.  D.,  Professor  of  Theoretical  and 
Applied  Pharmacy,  College  of  Pharmacy,  New  York.  Octavo,  550 
pages,  illustrated.     Ready  Shortly. 

Keating*s  Life  Insurance. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating,  M.  D., 
Fellow  of  the  College  of  Physicians  of  Philadelphia ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages.     With  numerous  illustrations.     Cloth,  ^2.00  net. 

Keen  on  the  Surgery  gf  Typhoid  Fever. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm. 
W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  the  Principles 
of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College,  Phila- 
delphia, etc.    Octavo  volume  of  386  pages,  illustrated.    Cloth,  ^3.00  net. 

Keen*S    Operation    Blank.       second  Edition.  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.,  Required  in  Vari- 
ous Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S. 
(Hon.),  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia.  Price  per  pad,  blanks  for  fifty 
op>erations,  50  cts.  net. 

Kyle  on  the  Nose  and  Throat,    second  Edition. 

Diseases  of  the  Nose  and  I'hroat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
Professor  of  I-^ryngology  and  Rhinology,  Jefferson  Medical  College, 
Philadelphia.  Octavo,  646  pages;  over  150  illustrations  and  6  litho- 
graphic plates.     Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  ^^5.00  net. 


MEDICAL  PUBLICATIONS 


Laine's  Temperature  Chart. 

By  D.  T.  Laine,  M.  D.  For  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  etc.  ;  with  the 
Brand  Treatment  of  Typhoid  Fever  on  the  back  of  each  chart.  Pad  of 
25  charts,  50  cts.  net. 

Levy,  Kletnperer,  and  Eshner's  Clinical  Bacteriology. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Pro- 
fessor in  the  University  of  Strasburg,  and  Felix  Klemperer,  Privat- 
docent  in  the  University  of  Strasburg.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadel- 
phia Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  ^2.50  net. 

Lockwood-s  Practice  ef  Medicine.         R.^'J^a'^MSed. 

A  Manual  of  the  Practice  of  Medicine.  By  George  E  oe  Lockwood, 
M.  D.,  Attending  Physician  to  Bellevue  Hospital,  New  York.  Octavo, 
847  pages,  illustrated,  including  22  colored  plates.     Cloth,  ^4.00  net. 

Long's  Syllabus  cf  Gynecology. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

Macdonald's  Surgical  Diagnosis  anb  Treatment. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.  D. 
Edin.,  F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical 
Surgery,  Hamline  University.  Handsome  octavo,  800  pages,  fully  illus- 
trated.    Cloth,  ^5.00  net;  Sheep  or  Half  Aforocco,  $6.00  net. 

Mallory  and  Wright's  Pathological  Technique. 

Second  Edition,  Revised. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank  B. 
Mallory,  A.M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.M., 
M.  D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.     Octavo,  432  pages,  fully  illustrated.     Cloth,  ^3.00  net. 

McClellan's  Anatomy  in  its  Relation  to  Art. 

Anatomy  in  its  Relation  to  Art.  An  Exposition  of  the  Bones  and 
Muscles  of  the  Human  Body,  with  Reference  to  their  Influence  upon 
its  Actions  and  External  Form.  By  George  McClellan,  M.  D., 
Professor  of  Anatomy,  Pennsylvania  Academy  of  Fine  Arts.  Hand- 
some quarto  volume,  9  by  ii}4  inches.  Illustrated  with  338  original 
drawings  and  photographs ;  260  pages  of  text.  Dark  Blue  Vellum, 
^10.00  net;  Half  Russia,  $12.00  net. 

McClellan's  Regional  Anatomy.    Fourth  Edition.  Revised. 

Regional  Anatomy  in  its  Relations  to  Medicine  and  Surgery.  By 
George  McClellan,  M.  D.,  Professor  of  Anatomy,  Pennsylvania  Acad- 
emy of  Fine  Arts.  Two  handsome  quarto  volumes,  884  pages  of  text, 
and  97  full-page  chromo-lithographic  plates,  reproducing  the  author's 
original  dissections.     Cloth,  $12.00  net;  Half  Russia,  $15.00  net. 


OF  W.   B.  SAUNDERS  &■   CO.  II 


McFarland's  Pathogenic  Bacteria.    ''Sf  gf^i-.tp^l" 

Text-Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  Medico-Chirurgical 
College  of  Philadelphia,  etc.  Octavo  volume  of  621  pages,  finely 
illustrated.     Cloth,  I3.25  net. 

Mei^s  on  Feeding  in  Infancy. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.  D.  Bound  in 
limp  cloth,  flush  edges,  25  cts.  net. 

Moore's  Orthopedic  Surg»ery. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.  D.,  Pro- 
fessor of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  Uni- 
versity of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume 
of  356  pages,  handsomely  illustrated.     Cloth,  ^2.50  net. 

Morten's  Nurses*  Dictionary. 

Nurses'  Dictionary  of  Medical  Terms  and  Nursing  Treatment.  Con- 
taining Definitions  of  the  Principal  Medical  and  Nursing  Terms  and 
Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treat- 
ments, Operations,  Foods,  Appliances,  etc.  encountered  in  the  ward  or 
in  the  sick-room.  By  Honnor  Morten,  author  of  "How  to  Become 
a  Nurse,"  etc.      i6mo,  140  pages.     Cloth,  ^i.oo  net. 

Nancrede's  Anatomy  and  Dissection.    Fourth  Edition. 

Essentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  Charles 
B.  Nancrede,  M.  D.,  LL.  D.,  Professor  of  Surgery  and  of  Clinical  Sur- 
gery, University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with 
full-page  lithographic  plates  in  colors  and  nearly  200  illustrations.  Extra 
Cloth  (or  Oilcloth  for  dissection-room),  ^2.00  net. 

Nancrede's  Principles  qf  Surgery. 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B,  Nancrede,  M.  D., 
LL.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of 
Michigan,  Ann  Arbor.   Octavo,  398  pages,  illustrated.    Cloth,  ^2.50  net. 

Norris's  Syllabus  qf  Obstetrics.    Third  Edition,  Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department  of  the 
University  of  Pennsylvania.  By  Richard  C.  Norris,  A.  M.,  M.  D., 
Instructor  in  Obstetrics  and  Lecturer  on  Clinical  and  Operative  Obstet- 
rics, University  of  Pennsylvania.  Crown  octavo,  222  pages.  Cloth, 
interleaved  for  notes,  $2.00  net. 

Ogden  on  the  Urine. 

Clinical  Examination  of  the  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Instructor  in  Chemistry,  Harvard 
Medical  School.  Handsome  octavo,  416  pages,  with  54  illustrations 
and  a  number  of  colored  plates.     Cloth,  ^3.00  net. 

Penrose's  Diseases  qf  Women.    Fourth  Edition.  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose,  M.  D., 
Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of  Penn- 
sylvania. Octavo  volume  of  539  pages,  221  illustrations.  Cloth, 
f.-i.Tc.   net ...-...._      _. 


MEDICAL  PUBLICATIONS 


Pye's  Banda£(in^. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  con- 
cerning the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter 
Pye,  F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small 
i2mo,  over  80  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

Pyle's  Personal  Hygiene. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic 
Basis.  Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the 
Wills  Eye  Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully 
illustrated.     Cloth,  $1.50  net. 

Raymond's  Physiology.     R.J^t^ridtS;.?EtS^ed. 

A  Text-Book  of  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  in  the  Long  Island  College 
Hospital,  and  Director  of  Physiology  in  Hoagland  Laboratory,  New 
York.     Octavo,  668  pages,  443  illustrations.     Cloth,  ^3.50  net. 

Robson  arid  Moynihan*s  Diseases  qf  the  Pancreas. 

Diseases  of  the  Pancreas.  By  A.  W.  Mayo  Robson,  F.  R.  C.  S., 
Leeds,  Senior  Surgeon  to  Leeds  General  Infirmary ;  Emeritus  Pro- 
fessor of  Surgery,  Yorkshire  College;  and  B.  G.  A.  Moynihan,  M.  B., 
F.  R.  C.  S.,  Assistant  Surgeon  Leeds  General  Infirmary;  Demonstrator 
of  Anatomy,  Yorkshire  College.  Handsome  octavo  of  300  pages, 
illustrated.     Cloth,  $0.00  net. 

Saling'er  and  Kalteyer's  Modern  Medicine. 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College ;  and  F.  J.  Kalteyer, 
M.  D.,  Assistant  Demonstrator  of  Clinical  Medicine,  Jefferson  Medical 
College.     Handsome  octavo,  801  pages,  illustrated.     Cloth,  ;^4.oo  net. 

Saundby's  Renal  and  Urinary  Diseases. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D. 
Edin.,  Fello^v  of  the  Royal  College  of  Physicians,  London,  and  of  the 
Royal  Medico-Chirurgical  Society ;  Professor  of  Medicine  in  Mason 
College,  Birmingham,  etc.  Octavo,  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  $2.50  net. 

Saunders'  Medical  Hand-Atlases. 

See  Pages   17,  18,  and  19. 

Saunders*  Pocket  Medical  Formulary,  sixth  Edition,  Revised. 

By  William  M.  Powell,  M.  D.,  author  of  "Essentials  of  Diseases  of 
Children";  Member  of  Philadelphia  Pathological  Society.  Contain- 
ing 1844  formulae  from  the  best-known  authorities.  With  an  Appendix 
containing  Posological  Table,  Fonnulse  and  Doses  for  Hypodermic 
Medication,  Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis 
and  Fetal  Head,  Obstetrical  Table,  Diet  Lists,  Materials  and  Drugs 
used  in  Antiseptic  Surgery.  Treatment  of  Asphyxia  from  DroAvning,  Sur- 
gical Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc. 
In  flexible  morocco,  with  side  index,  wallet,  and  flap.     ^2.00  net. 


OF  W.  B.  SAUNDERS  &-  CO.  13 

Saunders'  Question-Compends.    see  Page  16. 

Scudder*S   Fractures.       Third  Edition,  Revised. 

The  Treatment  of  Fractures.  By  Chas.  L.  Scudder,  M.  D.,  Assistant 
in  Clinical  and  Operative  Surgery,  Harvard  University  Medical  School. 
Octavo,  460  pages,  vi'ith  nearly  600  original  illustrations.  Polished 
Buckram,,  net ;    Half  Morocco,  net. 

Senn*s  Genito-Urinary  Tuberculosis. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.  By 
Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Surgery,  Rush 
Medical  College,  Chicago.  Handsome  octavo  volume  of  320  pages, 
illustrated.     Cloth,  $3.00  net. 

Senn's  Practical  Surgery. 

Practical  Surgery.  By  Nicholas  Senn,  M.  D.,  Ph.  D.,LL.  D.,  Pro- 
fessor of  Surgery,  Rush  Medical  College,  Chicago.  Octavo,  1133 
pages,  642  illustrations.  Cloth,  ^6.00  net;  Sheep  or  Half  Morocco, 
^7.00  net.     By  Subscription. 

Senn's  Syllabus  qf  Surgery. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  con- 
formity with  "An  American  Text-Book  of  Surgery."  By  Nicholas 
Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Surgery,  Rush  Medical  Col- 
lege, Chicago.     Cloth,  ^1.50  net. 

Senn's    Tumors.       second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  Nicholas  Senn,  M.  D.  , 
Ph.  D.,  LL.  D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  718  pages,  with  478  illustrations,  including 
12  full-page  plates  in  colors.  Cloth,  ^5.00  net ;  Sheep  or  Half  Morocco, 
^6.00  net. 

Sollmann's  Pharmacology. 

A  Text-Book  of  Pharmacology  :  including  Therapeutics,  Materia  Medica, 
Pharmacy,  Prescription-Writing,  Toxicology,  etc.  By  Torald  Soll- 
MANN,  M.  D.,  Assistant  Professor  of  Pharmacology  and  Materia  Medica, 
Western  Reserve  University,  Cleveland,  Ohio.  Handsome  octavo, 
894  pages,  fully  illustrated.     Cloth,  ^3.75  net. 

Starr's  Diets  for  Infants  ar^  Children. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By  Louis 
Starr,  M.  D.,  Editor  of  "An  American  Text-Book  of  the  Diseases  of 
Children."  230  blanks  (pocket-book  size),  perforated  and  neatly  bound 
in  flexible  morocco.     $1.25  net. 

Stelwagon's  Diseases  qf  the  Skin. 

Diseases  of  the  Skin.  l]y  Henry  W.  Stelwagon,  M.  D.,  Clinical  Pro- 
fessor of  Dermatology,  Jefferson  Medical  College,  Philadelphia.  Royal 
octavo,  over  1000  pages,  with  over  200  text-cuts  and  26  colored  plates. 
Cloth,  ^6.00  net;  Sheep  or  Half  Morocco,  I7.00  net. 


14  MEDICAL  PUBLICATIONS 

Stengel's    Pathology.      Third  Edition,  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  Alfred  Stengel,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania;  Visiting  Physician  to 
the  Pennsylvania  Hospital.  Handsome  octavo,  873  pages,  nearly  400 
illustrations,  many  of  them  in  colors.  Cloth,  $5 .  00  net ;  Sheep  or  Half 
Morocco,  $6.00  net. 

Stengel  and  White  on  the  Blood. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania ;  and  C.  Y.  White,  Jr.,  M.  D.,  Instructor  in  Clinical  Medicine, 
University  of  Pennsylvania.      /;/  Press. 

Stevens*    Theranetl+irs  Third  Edition.  Entirely 

Oieveni      1  nerapeUXICS.       Rewritten  and  Greatly  Enlarged. 

A  Text-Book  of  Modern  Therapeutics.    By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on    Physical   Diagnosis   in    the    University  of   Pennsylvania. 
Handsome  octavo  volume  of  about  550  pages.     Cloth,  $0.00  net. 

Stevens*  Practice  qf  Medicine.    Fifth  Edition,  Revised. 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania. Specially  intended  for  students  preparing  for  graduation  and 
hospital  examinations.  Post-octavo,  519  pages;  illustrated.  Flexible 
Leather,  $2.00  net. 

Stewart's    Physiology.       Fourth  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and 
Practitioners.  By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc.,  Professor  of 
Physiology  and  Histology,  Western  Reserve  University,  Cle\'eland, 
Ohio.  Octavo,  894  pages;  2iZ^  illustrations  and  5  colored  plates. 
Cloth,  33.75  net. 

Stoney*s  Materia  Medica  for  Nurses. 

Materia  Medica  for  Nurses.  By  the  late  Emily  A.  I\L  Stonev,  Superin- 
tendent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Bos- 
ton, Mass.     Handsome  octavo  volume  of  306  pages.      Cloth,  $1.50  net. 

StOney'S    Nursin|(.       second  Edition,  Revised. 

Practical  Points  in  Nursing.  For  Nurses  in  Private  Practice.  By  the 
late  EiMiLY  A.  M.  Stoney,  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  with  73 
engravings,  and  8  colored  and  half-tone  plates.     Cloth,  $1.75  net. 

Stoney*s  Surgical  Technic  for  Nurses. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  the  late  Emily  A.  M. 
Stoney,  Superintendent  of  the  Training  School  for  Nurses,  Carney  Hosp., 
South  Boston,  Mass.     i2mo  volume,  fully  illustrated.    Cloth,  $1.25  net. 

Thomas's    Diet   Lists.      second  Edition.  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  Jerome  B.  Thomas,  M.  D., 
Visiting  Physician  to  the  Home  for  Friendlecs  AVomen  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital.     Cloth,  ^1.25  net.     Send  for  sample  sheet. 


OF  IV.  B.  SAUNDERS  6-   CO. 


15 


Thornton's  Dose-Book  and  Prescription-Writing. 

Second  Edition,  Revised  and  Enlarged. 

Dose-Book  and  Manual  of  Prescription- Writing.  By  E.  Q.  Thornton, 
M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila. 
Post-octavo,  362  pages,  illustrated.      Flexible  Leather,  ^2.00  net. 

Vecki'S    Sexual    Impotence.        Third  Edition.  Revised  and  Enlarged. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor  G. 
Vecki,  M.  D.  From  the  second  German  edition,  revised  and  enlarged. 
Demi-octavo,  329  pages.     Cloth,  ^2.00  net. 

Vierordt*s  Medical  Diagnosis.     Fourth  Edition.  Revised. 

Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth 
enlarged  German  edition,  with  the  author's  permission,  by  Francis  H. 
Stuart,  A.M.,  M.  D.  Handsome  octavo  volume,  603  pages;  194 
wood-cuts,  many  of  them  in  colors.  Cloth,  ^4.00  net;  Sheep  or  Half 
Morocco,  $5.00  net. 

Watson's  Handbook  for  Nurses. 

A  Handbook  for  Nurses.  By  J.  K.  Watson,  M.  D.  Edin.  American 
Edition,  under  supervision  of  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer 
on  Physical  Diagnosis,  University  of  Pennsylvania.  i2mo,  413  pages, 
73  illustrations.      Cloth,  ^1.50  net. 

Warren's  Sur|(ical  Pathology,    second  Edition. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard 
Medical  School.  Handsome  octavo,  873  pages;  136  relief  and  litho- 
graphic illustrations,  ^  in  colors.  With  an  Appendix  on  Scientific 
Aids  to  Surgical  Diagnosis,  and  a  series  of  articles  on  Regional  Bacte- 
riology.    Cloth,  $5.00  net;   Sheep  or  Half  Morocco,  ^6.00  net. 

Warwick  and  TunstalPs  First  Aid  to  the  Injured  and 
Sick. 

First  Aid  to  the  Injured  and  Sick.  By  F.  J.  Warwick,  B.  A.,  M.  B., 
Cantab.,  M.  R.  C.  S.,  Surgeon-Captain,  Volunteer  Medical  Staff  Corps, 
London  Companies;  and  A.  C.  Tunstall,  M.  D.,  F.  R.  C.  S.  Ed., 
Surgeon-Captain  commanding  East  London  Volunteer  Brigade  Bearer 
Company.     i6mo,  232  pages;  nearly  200  illustrations.    Cloth,  $1.00  net. 

Wolfs  Examination  qf   Urine. 

A  Handbook  of  Physiologic  Chemistry  and  Urine  Examination.  By 
Chas.  G.  L.  Wolf,  M.  D.,  Instructor  in  Physiologic  Chemistry,  Cornell 
University  Medical  College.  i2mo,  204  pages,  illustrated.  Cloth,  ^1.25 
net. 


SAUNDERS* 
QUESTION-COMPEND  SERIES. 

Price,  Cloth,  $1.00  net  per  copy,  except  when  otherwise  noted. 


"  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders  Series, 
in  our  opinion,  bears  off  the  palm  at  present." — New  York  Medical  Record. 


1.  Essentials  of  Physiology.     By  Sidney  Budgett,  M.  D.     A  N^w  Work. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.  D.     Seventh  edition,  revised,  with 

an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By  Charles   B.   Nancrede,   M.  D.     Sixth  edition,  thor- 

oughly  revised  and  enlarged. 

4.  Essentials  of  Mediced  Chemistry,  Orgjinic  and  Inorganic.     By  Lawrenck  Wolff, 

M.  D.      Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.  D.     Fifth   edition,  revised 

and  enlarged. 

6.  Eissentials  of  Pathology  and  Morbid  Anatomy.     By  F.  J.  Kalteyer,  M.  D.     In 

preparation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  £ind  Prescription- Writing.    Bj  Henry 

Morris,  M.  D.      Fifth  edition,  revised. 

8.  9.    Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Appendix 

on  Urine  Ex.^mination.  By  Lawrence  Wolff,  M.  D.  Third  edition,  enl«xged 
by  some  300  Essential  Formulae,  selected  from  eminent  authorities,  by  Wm.  M. 
Powell,  M.  D.     (Double  number,  ^1.50  net.) 

10.  Essentials  of  Gynecology.     By  Edwin  B.  Cragin,  M.  D.     Fifth  edition,  revised. 

11.  Essentials  of  Diseases  of  the  Skin.     By  Henry  W.  Stelwagon,  M.  D.     Fourth 

edition,  revised  and  enlarged. 

12.  Essentieds  oi  Minor  Surgery,  Bandaging,  zmd  Veneread   Diseases.     By  Edward 

Martin,  M.  D.     Second  edition,  revised  and  enlarged. 

I3<    EssentizJs    of   Legal    Medicine,   Toxicology,   and   Hygiene.     This  volume   is   at 
present  out  of  print. 

14.  Essentials  of  Diseases  of  the  Eye.     By  Edward  Jackson,  M.  D.     Third  edition, 

revised  and  enlarged. 

15.  Essentials  of  Diseases  of  Children.    By  William  M.  Powell,  M.  D.    Third  edition. 

16.  Essentials    of    Extunination    of    Urine.     By    Lawrence   Wolff,   M.  D.      Colored 

"  VoGEL  Scale."      (75   cents  net.) 

17.  Essentials  of  Diagnosis.     By  S.   Solis-Cohen,  M.  D.,  and  A.   A.  Eshner,  M.  D. 

Second  edition,  thoroughly  revised. 

18.  Essentisds    of    Practice    of    Pharmacy.     By  Lucius   E.    Sayre.     Second   edition, 

revised  and  enlarged. 

19.  Essentials  of  Diseases  of  the  Nose  and  Throat.     By  E.  B.  Gleason,  M.  D.     Third 

edition,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  V.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  Insanity.     By  John  C.  Shaw,  M.  D.     Third 

edition,  revised. 

22.  Essentials  of   Medical    Physics.     By  Fred  J.   Brockway,  M.  D.     Second  edition, 

revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  M.  D.,  and  Edward 

S.  Lawrance,  M.  D. 

24.  Essentials  of   Diseases  of   the  Ear.     By  E.   B.  Gleason,  M.  D.     Third   edition, 

revised  and  greatly  enlarged. 

25.  Essentials  of  Histology.     By  Louis  Leroy,  M.  D.     Second  edition,  revised.     With 

85  original  illustrations. 

Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 

16 


Saunders'  Medical    Hand-Atlases. 


VOLUMES    NOW   READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With 
182  colored  figures  on  68  plates,  64  text-illustrations,  259  pages  of  text. 
Cloth,  ^3.00  net. 

Atlas  of  he^al  Medicine. 

By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited  by  Frederick 
Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of 
Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates  and  193  beautiful  half-tone  illustrations.     Cloth,  ^3.50  net. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx. 

By  Dr.  L.  Grunwald,  of  Munich.  Edited  by  Charles  P.  Grayson, 
M.  D. ,  Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of 
the  University  of  Pennsylvania.  With  107  colored  figures  on  44  plates, 
25  text-illustrations,  and  103  pages  of  text.     Cloth,  ^2.50  net. 

Atlas  and  Epitome  of  Operative  Surgery. 

Second  Edition,  Thoroughly  Revised  and  Greatly  Enlarged. 

By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited  by  J.  Chalmers 
DaCosta,  M.  D.,  Professor  of  Principles  of  Surgery  and  of  Clinical  Sur- 
gery, Jefferson  Medical  College,  Phila.  With  40  colored  plates,  278 
text-illustrations,  and  410  pages  of  text.     Cloth,  ^3.50  net. 

Atlas   and   Epitome   of    Syphilis    and  the  Venereal 
Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton 
Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  71  colored 
plates,  16  illustrations,  and  122  pages  of  text.     Cloth,  ^3.50  net. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Phila.  With  76 
colored  figures  on  40  plates;  228  pages  of  text.     Cloth,  ^3.00  net. 

Atlas  and  Epitome  of  Skin  Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
WAGON,  M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical 
College,  Philadelphia.  With  6;^  colored  pjlates,  39  half-tone  illustra- 
tions, and  200  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Special  Pathological  Histology. 

By  Dr.  H.  Dltrck,  of  Munich.  Edited  by  Ludvig  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.,  including  Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts, 
120  colored  figures  on  62  plates,  158  pages  of  text.  Part  II.,  including 
Liver,  Drinary  Organs,  Sexual  Organs,  Nervous  System,  Skin,  Muscles, 
and  Bones,  123  colored  figures  on  60  plates,  and  192  pages  of  text. 
Per  jart :   Clolh,  $3.00  net. 

17 


Saunders'  Medical  Hand-Atlases. 

VOLUMES  JUST  ISSUED. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Translated  and  edited,  with 
additions,  by  Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Depart- 
ment of  Corrections  and  to  the  Almshouse  and  Incurable  Hospitals, 
New  York.  With  40  colored  plates,  143  text-illustrations,  and  1549 
pages  of  text.     Cloth,  ^4.00  net. 

Atlas  and  Epitome  of  Gynecolo|(y. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  Ger- 
man Edition.  Edited,  with  additions,  by  Richard  C.  Norris,  A.  M., 
M.  D.,  Gynecologist  to  the  Methodist  Episcopal  and  the  Philadelphia 
Hospitals  ;  Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  AN^ith 
90  colored  plates,  65  text-illustrations,  and  308  pages  of  text.  Cloth, 
^3.50  net. 

Atlas  and  Epitome  of  the  Nervous  System  and  its 
Diseases. 

By  Prof.  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Revised  and 
Ffilarged  German  Edition.  Edited,  with  additions,  by  Edward  D. 
Fisher,  M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University 
and  Bellevue  Hospital  Medical  College,  N.  Y.  With  83  plates ;  copious 
text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  atid 
Enlarged  German  Edition.  Edited,  with  additions,  by  J.  Clifton 
Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell 
University  Medical  School.  With  I2i5  colored  illustrations.  Cloth, 
$2.00  net. 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treat- 
ment. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  J.  Clifton 
Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell 
University  Medical  School.  72  colored  plates,  text-illustrations,  and 
copious  text.     Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthal- 
moscopic Diaglnosis. 

By  Dr.  O.  Haab,  of  Zurich.  From  the  Tliird  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  G.  E.  de  Schweinitz, 
M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical  College,  Phila- 
delphia. With  152  colored  figures  and  82  pages  of  text.  Cloth,  ^3.00 
net. 

ADDITIONAL  VOLUMES  IN  PREPARATION. 

18 


Saunders'  Medical  Hand-Atlases. 

VOLUMES  JUST   ISSUED. 

Atlas  and  Epitome  of  Bacteriology. 

Including  a  Hand-Book  of  Special  Bacteriologic  Diagnosis.  By  Prof. 
Dr.  K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  WUrzburg.  F7'om 
the  Second  Enlarged  and  Revised  German  Edition.  Edited,  with  addi- 
tions, by  G.  H.  Weaver,  M.  D.,  Assistant  Professor  of  Pathology  and 
Bacteriology,  Rush  Medical  College,  Chicago.  In  Two  Parts.  Part  I., 
consisting  of  632  colored  illustrations  on  69  lithographic  plates.  Part  II., 
consisting  of  5  1 1  pages  of  text,  illustrated.      Per  part:  Cloth,  $2.50  net. 

Atlas  and  Epitome  of  Otology. 

By  Dr.  Gustav  Bruhl,  of  Berlin,  with  the  collaboration  of  Prof.  Dr. 
A.  Politzer,  of  Vienna.  Edited,  with  additions,  by  S.  MacCuen 
Smith,  M.  D.,  Clinical  Professor  of  Otology,  Jefferson  Medical  College, 
Philadelphia.  244  colored  figures  on  39  plates,  99  text-cuts,  and  292 
pages  of  text.      Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Abdominal  Hernias. 

By  Privatdocent  Dr.  Georg  Sultan,  of  Gottingen.  Edited,  with 
additions,  by  William  B.  Coley,  Clinical  Lecturer  on  Surgery,  Colum- 
bia University  (College  of  Physicians  and  Surgeons),  New  York ;  Sur- 
geon to  the  General  Memorial  Hospital,  New  York.  With  43  colored 
figures,  on  36  plates,  100  text-cuts,  and  250  pages  of  text.      In  Press. 

Atlas  and  Epitome  of  Fractures  and  Luxations. 

By  Prof.  Dr.  H.  Helferich,  of  Greifswald.  Edited,  with  additions,  by 
Joseph  C.  Bloodgood,  Associate  in  Surgery,  Johns  Hopkins  University, 
Baltimore.  With  215  colored  figures  on  72  plates,  144  text-cuts,  42 
skiagraphs,  and  over  300  pages  of  text.     In  Press. 

Atlas  and  Epitome  of  Diseases  of  Mouth,  Throat,  and 
Nose. 

By  Dr.  L.  Grunwald,  of  Munich.  From  the  Second  Revised  a?id 
Enlarged  German  Edition.  Edited,  with  additions,  by  James  E.  New- 
COMB,  M.  D.,  Clinical  Instructor  in  Laryngology,  Cornell  University 
Medical  School.  With  42  colored  figures,  39  text-cuts,  and  225  pages 
of  text.      In  Press. 

Atlas  and  Epitome  of  Normal  Histology. 

By  Privatdocent  Dr.  J.  Sobotta,  of  Wiirzburg.  Edited,  with  addi- 
tions, by  G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and 
Director  of  the  Histological  Laboratory,  University  of  Michigan.  With 
80  colored  figures  and  68  text-cuts  from  the  original  of  W.  Freytag,  and 
275  pages  of  text. 

Atlas  and  Epitome  of  Operative  Gynecology. 

By  Dr.  Oskar  Schakffer,  Privatdocent  at  the  University  of  Heidel- 
berg. With  42  colored  figures  and  21  text-cuts  from  the  original  of  A. 
Schmitson,  and  125  pages  of  text. 

ADDITIONAL  VOLUMES  IN   PREPARATION. 
19 


NOTHNAGEL'S   ENCYCLOPEDIA 

OF 

PRACTICAL  MEDICINE 

AMERICAN  EDITION 

Edited    by  ALFRED   STENGEL,  M.  D. 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Visiting 
Physician  to  the  Pennsylvania  Hospital 

IT  is  universally  acknowledged  that  the  Germans  lead  the  world   in  Internal 
Medicine  ;  and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Speci- 

elle  Pathologie  und  Therapie  "  is  conceded  by  scholars  to  be  without  question 
the  best  System  of  Medicine  in  existence.  So  necessary  is  this  book  in  the  study 
of  Internal  Medicine  that  it  comes  largely  to  this  country  in  the  original  German. 
In  view  of  these  facts,  Messrs.  W.  B.  Saunders  &  Company  have  arranged  with 
the  publishers  to  issue  at  once  an  authorized  American  edition  of  this  great  ency- 
clopedia of  medicine. 

For  the  present  a  set  of  ten  volumes,  representing  the  most  practical  part 
of  this  excellent  encyclopedia,  and  selected  with  especial  thought  of  the  needs 
of  the  practical  physician,  will  be  published.  These  volumes  will  contain  the 
real  essence  of  the  entire  work,  and  the  purchaser  will  therefore  obtain  at  less 
than  half  the  cost  the  cream  of  the  original.  Later  the  special  and  more  strictly 
scientific  volumes  will  be  offered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both 
English  and  German,  and  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to 
date,  and  the  American  edition  will  be  more  than  a  mere  translation  of  the  Ger- 
man ;  for,  in  addition  to  the  matter  contained  in  the  original,  it  will  represent  the 
very  latest  views  of  the  leading  American  and  English  specialists  in  the  various 
departments  of  Internal  Medicine.  The  whole  System  will  be  under  the  edi- 
torial supervision  of  Dr.  Alfred  Stengel,  who  will  select  the  subjects  for  the 
American  edition,  and  arrange  for  the  editing  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended 
over  a  number  of  ye?irs,  but  five  or  si.x  volumes  will  be  issued  during  the  coming 
year,  and  the  remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume 
will  be  revised  to  the  date  zi  its  publication  by  the  eminent  editor.  This  will 
obviate  the  objection  that  has  heretofore  existed  to  systems  published  in  a  number 
of  volumes,  since  the  subscriber  will  receive  the  completed  work  while  the  earlier 
volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been 
to  compel  physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases 
to  be  undesirable.  Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be 
given  the  opportunity  of  subscribing  for  the  entire  System  at  one  time  ;  but  any 
single  volume  or  any  number  of  volumes  may  be  obtained  by  those  who  do  not 
desire  the  complete  series.  This  latter  method,  while  not  so  profitable  to  the  pub- 
lisher, offers  to  the  purchaser  many  advantages  which  will  be  appreciated  by  those 
who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question, 
form  the  greatest  System  of  Medicine  ever  produced,  and  the  publishers  are  con- 
fident that  it  will  meet  with  general  favor  in  the  medical  profession. 

20 


NOTHNAGEL'S 
ENCYCLOPEDIA   OF   PRACTICAL  MEDICINE. 

AMERICAN    EDITION. 

VOLUMES  JUST  ISSUED  AND  IN   PRESS. 

TYPHOID  AND  TYPHUS  FEVERS.     By  Dr.  H.  Curschmanx,  of  Leipsic. 

Editor,  William  Osier,  M.D.,  F.R.C.P.,  Professor  of  the  Principles  and  Practice  of 
Medicine  in  Jonns  Hopkins  University,  Baltimore.  Handsome  octavo,  646  pages, 
72  valuable  text  illustrations,  and  two  lithographic  plates.  Cloth,  ^5.00  net;  Half 
Morocco,  ^6.00  net.     Just  Ready. 

VARIOLA  (including  VACCINATION j.  By  Dr.  H.  Immermann,  of  Basle.  VARI- 
CELLA. By  Dii.  Th.  von  Ji:j'rgensen,  of  Tubingen.  CHOLERA  ASIATICA 
and  CHOLERA  NOSTRAS.  By  Dr.  C.  Liebermeistkr,  of  Tubingen.  ERY- 
SIPELAS and  ERYSIPELOID.  By  Dr.  H.  Lenhartz,  of  Hamburg.  PER- 
TUSSIS and  HAY-FEVER.  By  Dr.  G.  Sticker,  of  Giessen. 
Editor,  Sir  J.  W.  Moore,  B.A.,  M.D.,  F.R.C.P.I.,  Professor  of  the  Practice  of  Medi- 
cine, Royal  College  of  Surgeons,  Ireland.  Handsome  octavo  of  682  pages,  illustrated. 
Cloth,  ^5.00  net;    Half  Morocco,  ^6.00  net.     Just  Ready. 

DIPHTHERIA.     An   oriijinal    article   by  William    P.  Northrup,   M.D.,  of  New  York. 
Measles,  Sceirlet  Fever,  Rotheln.      By  Dr.  Th.  von  Jurgensen,  of  TiilMngen. 
Editor,  William  P.  Northrup,  M.  D.,   Professor  of  I'ediatrics,  University  and  Bellevue 

Medical  College,  N.  V^  Handsome  octavo,  672  pages,  illustrated,  including  24  full- 
page  plates,  3  in   colors.      Cloth,  $5.00  net  ;    Half  INlorocco,  ^6.00  net.     JuU  Ready. 

DISEASES  OF  THE  BRONCHI.  Bv  Dr.  F.  A.  PIoffmann,  of  Leipsic.  DIS- 
EASES OF  THE  PLEURA.  By  Dr.  O.  Rosenbaum,  of  Berlin.  PNEUMONIA. 
By  Dr.  E.  Aufrecht,  of  Magdeburg. 

Editor,  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania. Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors.  Cloth,  ^5.00 
net  ;   Half  Morocco,  ^6.00  net.     just  Ready. 

DISEASES  OF  THE  LIVER.  Bv  Drs.  H.  Quincke  and  G.  Hoppe-Seyler,  of  Kiel. 
DISEASES  OF  THE  PANCREAS.     By  Dr.  L.  Oser,  of  Vienna.     DISEASES 

OF  THE  SUPRARENALS.     By  Dr.  E.  Neusser,  of  Vienna. 

Editors,  Frederick  A.  Packard,  M.D.,  Physician  to  the  Penna.  and  the  Children's 
Hospitals,  Phila.  ;  and  Reginald  H.  Fitz,  A.  M.,  M.  D.,  Hersey  Prof,  of  the  Theory 
and  Practice  of  Physic,  Harvard  Univ.  Handsome  octavo  of  750  pages,  illustrated. 
Cloth,  j^5.oo  net;   Half  Morocco,  ^6.00  net.     Just  Ready. 

INFLUENZA  AND  DENGUE.  By  Dr.  O.  Leichtenstern,  of  Cologne.  MALA- 
RIAL DISEASES.      By  Dr.  J.    Mannaberg,  of  Vienna. 

Editor,  Ronald  Ross,  F.R.C.S.,  Eng.,  D.P.H.,  F.R.S.,  Major,  Indian  Medical 
Service,  retired;  Walter  Myers,  Lecturer,  Liverpool  School  of  Tropical  Medicine, 
Liverpool.      Handsome  octavo,  700   pages,  7  full-page  lithographs  in  colors. 

ANEMIA,  LEUKEMIA,  PSEUDOLEUKEMIA,  HEMOGLOBINEMIA.     By  Dr.  P. 

Ehrlich,  of  Frankfort-on-the-Main,  fjR.  A.  Lazarus,  of  Chaiiottenburg,  ai^d  Dr. 
Felix  Pinkus,  of  Berlin.  CHLOROSIS.  By  Dr.  K.  von  Noorden,  of  Frank- 
fort-on-the-Main. 

Editor,  Alfred  Stengel,  M.D.,  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania.     Handsome  octavo,  750  pages,  5  full-page  lithographs  in  colors. 

TUBERCULOSIS  AND  ACUTE    GENERAL    MILIARY   TUBERCULOSIS.     By 

Dr.  G.  Cornet,  of  Berlin. 

Editor  to  be  announced  later.      Handsome  octavo,  700  pages. 

DISEASES  OF  THE  STOMACH,     By  Dr.  F.  Riegel,  of  Giessen. 

Ivlitor,  Charles  G.  Stockton,  M.D.,  Professor  of  Medicine,  University  of  Buffalo. 
Handsome  octavo,  800  p.ig'-s,  witii  29  text-cuts  and  6  full-page  ])lates. 

DISEASES   OF  THE    INTESTINES  AND   PERITONEUM.     By  Dr.  Hermann 

No-|-|ina';ki.,  of  Vienna. 

Editor,  Humphry  D,  Rolleston,  M.D.,  F.R.C.P.,  Physician  to  and  Lecturer  on  Pathol- 
ogy at  .St.  George's  1  iosjiital,  London.    Handsome  octavo,  800  pages,  finely  illustrated. 

21 


CLASSIFIED  LIST 

OF  THE 

MEDICAL    PUBLICATIONS 


OF 


W.  B.  SAUNDERS  O  COMPANY 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Bbhm.Davidoff,  and Huber— Histology,  .  4 

Clarkson— A  Text-Book  ot  Histology,'.    .  5 

Haynes— A  Manual  of  Anatomy,  ....  8 

Helsler— A  Text-Book  of  Embryology',  .    .  8 

Leroy — Essentials  of  Histology 16 

McClellan — Art  Anatomy,    .  '. 10 

McClellan^Regional  Anatomy, 10 

Nancrede — Essentials  of  Anatomy 16 

Nancrede — Essentials   of     Anatomy    and 

Manual  of  Practical  Dissection,  .'  .    .    .  11 

Sobotta — Atlas  of  Normal  Histology,    .    .  19 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology 16 

EjTe — Hacteriologic  Technique 7 

Frothlngham — Laboratory  Guide 7 

Gorbani — Laboratory  Bacteriology,   ...  7 
Lehmann  and  Neumann— Atlas  of  Bacte- 
riology   19 

Levy  and  Klemperer's  Clinical  Bacteri- 
ology   10 

Mallory  and  Wright— Pathological  Tech- 
nique,    lo 

McFaxland— Pathogenic  Bacteria 11 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart 8 

Keen — Operation  Blank 9 

Laine — Temperature  Chart 10 

meigs — Feeding  in  Early  Infancy 11 

Starr— Diets  for  Infants' and  Children,  .    .  13 

Thomas — Diet-Lists 14 

CHEMISTRY  AND  PHYSICS. 

Brockway— Essentials  of  Medical  Physics,  16 
JelliflFe  and  Diekman— Chemistry,    ...     9 

Wolf — Urine  Examination, m 

WolflF— Essentials  of  Medical  Chemistry,  .  16  ! 

CHILDREN. 

American  Text-Book  Dis.  of  Children,  .   .  i 

Griffith— Care  of  the  Baby 8 

Griffith— Infant's  Weight  Chart, 8 

Meigs— Feeding  in  Early  Infancy 11 

Powell — Essentials  of  Diseases  of  Children,  16 

Starr— Diets  for  Infants  and  Children,  .    .  13 

DIAGNOSIS. 
Cohen  and  Eshner— Essentials  of  Diag- 
nosis,     j6 

Corwin — Physical  Diagnosis, 5 

Vierordt — Medical  Diagnosis 15 

DICTIONARIES. 

The  American  Illustrated  Medical  Dic- 
tionary      3 

The  American  Pocket  Medical  Dictionary,      3 
Morten — Nurses'  Dictionary 11 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases  of 

the  Eve,  Ear,  Nose,  and  Throat r 

Briihl  and  Politzer— Atlas  of  Otology,      .  19 
■neSchweinitz— Diseases  of  the  Eye,    .    .  6 
Friedrich  and  Curtis— Rhinology,  Laryn- 
gology and  Otology 7 

Gleason — Essentials  of  Diseases  of  the  Ear,  16 

Gleason — Ess.  of  Dis.  of  Nose  and  Throat,  16 

Gradle — Ear,  Nose,  and  Throat, 7 

Grant — -Surgery  of  Face,  Mouth,  and  Jaws,  8- 
Grtinwald— Atlas  of  Mouth,  Throat",  and 

Nose 19, 

Grtinwald— -A.tlas     of    Diseases     of    the 

Larynx 17 

Haah — Atlas  of  External  Diseases  of  the 

Eye 17 

Haah — Atlas  of  Ophthalmoscopy 18. 

Jackson — Manual  of  Diseases  of  the  Eye,  9 

Jackson — Essentials   of   Diseases  of  Eye,  16 

Kyle — Diseases  of  the  Nose  and  Throat,  .  9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito-TJri- 

nary  and  Skin  Diseases 2: 

Hyde  and  Montgomery— Syphilis  and  the 

[      Venereal  Diseases 8 

'  Martin — Essentials     of    Minor    Surgery, 
Bandaging,  and  Venereal  Diseases,     .    .    16 
Mracek — Atlas  of  Syphilis  and  the  Vene- 
real Diseases 17 

Saundhy — Renal  and  Urinary  Diseases,  .  .  12 
Senn — Genito-Urinary  Tuberculosis,  ...  13 
Vecki — Sexual  Impotence, 15. 

GYNECOLOGY. 

American  Text-Book  of  Gynecology,    .    .  2 

Cragin — Essentials  of  Gynecology 16 

Garrigues — Diseases  of  Women 7 

Long — Syllabus  of  Gynecology 10 

Penrose — Diseases  of  Women 11 

Schae£rer — Atlas  of  Operative  Gynecology,  19 

SchaefiFer— Atlas  of  Gynecology,     .    .    .    .  i8' 

HYGIENE. 

Ahhott — Hygiene  of  Transmissible  Diseases    4 

Bergey — Principles  of  Hygiene 4 

Pyle — Personal  Hygiene, 12 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

American  Text-Book  of  Therapeutics,  .  .  r 
Butler — Text-Book    of    Materia    Medica, 

Therapeutics,  and  Pharmacology,    ...  S 

Morris — Ess.  of  M.  M.  and  Therapeutics,  i6' 

Saunders'  Pocket  Medical  Formulary,  .    .  12 

Sayre — Essentials  of  Pharmacy, 16 

Sollmann — Text- Book  of  Pharmacology,  .  13 

Stevens — Manual  of  Therapeutics,    ...  14 

Stoney — Materia  Medica  for  Nurses,   .    .  14 

Thornton — Prescription- Writing,    ....  15. 


MEDICAL  PUBLICATIONS  OF  W.  B.  SAUNDERS  &-  CO.   23 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Cliapman — Medical  Jurisprudence  and 
Toxicology 5 

Crothers — Morphinism 6 

Golebiewski — Atlas  of  Diseases  Caused  by 
Accidents, i8 

Hofmann— Atlas  of  Legal  Medicine,  .    .    .    17 

NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Brower — Manual  of  Insanity S 

Cbapin — Compendium  of  Insanity,    ...  5 
Cliurcli  and  Peterson — Nervous  and  Men- 
tal Diseases 5 

Jakob — Atlas  of  Nervous  System,  .        .    .  18 
Shaw — Essentials  of  Nervous  Diseases  and 

Insanity 16 

NURSING. 

Davis — Obstetric  and  Gynecologic  Nursing,    6 

Griffith— The  Care  of  the  Baby 8 

Meigs — Feeding  in  Early  Infancy 11 

Morten — Nurses'  Dictionary 11 

Stoney — -Materia  Medica  for  Nurses,      .    .  14 

Stoney — Practical  Points  in  Nursing,      .    .  14 

Stoney — Surgical  Technic  for  Nurses,    .    .  14 

Watson — Handbook  for  Nurses 15 

OBSTETRICS. 
An  American  Text-Book  of  Obstetrics,    .      2 

Ashton — Essentials  of  Obstetrics 16 

Boislini^re — Obstetric  Accidents,  ....      4 

Borland — Modern  Obstetrics 6 

Hirst— Text-Book  of  Obstetrics 8 

Norris — Syllabus  of  Obstetrics 11 

Schaeffer — Atlas  of  Labor  and  Operative         ; 

Obstetrics .    .  18  : 

Sdiaeffer — Atlas  of  Obstetrical  Diagnosis 

and  Treatment iS 

PATHOLOGY. 
An  American  Text-Book  of  Pathology,    .  2 
Durck — Atlas  of  Pathologic  Histology,  .    .  17 
Kalteyer — Essentials  of  Pathology,    ...  16 
Mallory  and  Wright— Pathological  Tech- 
nique   10 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors,    .    .  ' 13 

Stengel — Text-Book  of  Pathology,    .        .  14 

Stengel  and  White — Blood 14 

Warren — Surgical  Pathology  and  Thera- 
peutics   15 

PHYSIOLOGY. 

An  American  Text-Book  of  Physiology,  2 

Budgett—l'^ssentials  of  Physiology,    .    .    .  16 

Raymond— Human  Physiology 12 

Stewart— Manual  of  Physiology 14 

PRACTICE  OF  MEDICINE. 

An  American  Year-Book  of  Med,  &Surg.,  3 

An  American  Text-Book  of  Theo.  &  Prac,  3 

Anders-  I 'ractice  of  Medicine 4 

Eichhorst— Practice  of  Medicine 6 

Lockwood — Manual    of    the    Practice    of 

M'-dicine 10 

Morris — I^ss.  of  Practice  of  Medicine,  .    .  16 

Nothnagel's  I^ncydopedia 20,  21 

Salinger  and  Kalteyer— .Mod.  Medicine,  12 

Stevens — .Manual  of  I'ractice  of  Medicine,  14 


SKIN  AND  VENEREAL. 

An    American    Text-Book     of    Genito- 
urinary and  Skin  Diseases 2 

Hyde  and  Montgomery— Syphilis  and  the 

Venereal   Diseases 8 

Martin — Essentials    of     Minor     Surgery, 

Bandaging,  and  Venereal  Diseases,    .    .  16 

Mracek — Atlas  of  Diseases  of  the  Skin,    .  17 

Stelwagon^Diseases  of  Skin, 13 

Stelwagon—  Ess.  of  Diseases  of  the  Skin,  16 

SURGERY. 

An  American  Text-Book  of  Surgery,   .    .  2 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Beck — Fractures 4 

Beck — Manual  of  Surgical  Asepsis,     ...  4 

DaCosta — Manual  of  Surgery 6 

Helferich — Atlas  of  Fractures, 19 

International  Text-Book  of  Surgery,   .   .  9 

Keen — Operation  Blank 9 

Keen — The    Surgical   Complications    and 

Sequels  of  Typhoid  Fever 9 

Macdonald — Surgical  Diagnosis  and  Treat- 
ment   10 

Martin — Essentials    of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,    .    .  16 

Martin — Essentials  of  Surgery, 16 

Moore — Orthopedic  Surgery 11 

Nancrede — Principles  of  Surgery,  ....  11 

Pye — Bandaging  and  Surgical  Dressing,    .  12 

Scudder — Treatment  of  Fractures,     ...  13 

Senn — Genito-Urinary  Tuberculosis,  ...  13 

Senn — Practical  Surgery 13 

Senn — Syllabus  of  Surgery 13 

Senn — Tumors 13 

Sultan — Atlas  of  Abdominal  Hernia,     .    .  19 
Warren — Surgical  Pathology  and  Thera- 
peutics   15 

Zuckerkandl — Atlas  of  Operative  Surgery,  17 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical  Examination  of  the  Urine,    11 
Saundby — Renal  and  Urinary  Diseases,    .    12 

Wolf — Urine  Examination 15 

Wolff — Essendals  of  Examination  of  Urine,  16 

MISCELLANEOUS. 

Bastin — Laboratory  Exercises  in  Botany,  .     4 
Galbraith — Four     Epochs    of    Woman's 

Life, 7 

Golebiewski — Atlas    of    Diseases  Caused 

by  Accidents 18 

Gould  and  Pyle — Anomalies  and  Curiosi- 
ties of  Medicine 7 

Grafstrom — Massage 8 

Keating — Examination  for  Life  Insurance,      9 
Robson  and  Moynihan — Diseases  of  the 

Pancreas, 12 

Saunders'  Medical  Hand-Atlases,  .  17,  18,  19 
Saunders'  Pocket  Medical  P'ormulary,  .    .    12 

Saunders'  Question-Compends 16 

Stewart    and    Lawrance  -Essentials   of 

I       Medical  Electricity, 16 

Thornton — Dose-Book     and     Manual    of 

I'rcscription-Writing IS 

Warwick  and  Tunstall— First  Aid  to  the 
Injured  and  Sick 15 


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